Ucla 30910 Form PDF Details

The UCLA 30910 form, a pivotal document within the healthcare system, facilitates the controlled release of protected health information (PHI) to specified recipients under the patient's directive. By meticulously specifying the type of records to be released—ranging from medical and mental health records to billing statements and laboratory reports—the form plays a crucial role in ensuring that sensitive health information is shared responsibly and with explicit consent. It accommodates requests for record delivery through various modes, including CDs, paper copies, or emails (with noted exceptions), and clearly outlines the proposed recipient of the information, whether it be another healthcare facility, a designated individual, or for other specified reasons. The form further empowers patients through the ability to revoke the authorization at any point, underscoring the emphasis on patient autonomy and privacy. Sensitive information, such as details pertaining to drug and alcohol abuse, genetic testing, or HIV/AIDS test results, is handled with an additional layer of discretion, requiring specific authorization for release. The form's design reflects a comprehensive approach to the management of PHI, adhering to legal requirements while prioritizing patient rights and the confidentiality of their health information.

QuestionAnswer
Form NameUcla 30910 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesucla medical release, ucla release form, ucla medical records form, ucla medical records

Form Preview Example

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

MRN:

Patient Name:

(Patient Label)

Patient

Patient Name: ________________________________MRN: _________________

Information

 

Address: ________________________________________________________

 

City, State & Zip Code: _____________________________________________

 

Date of Birth (MMDDYYYY): _________________Phone: (

)_______________

 

 

 

 

 

 

Specify

UCLA Health Hospitals/Clinics

 

 

 

Healthcare

Jules Stein Eye Institute

 

 

 

Facility

Resnick Neuropsychiatric Hospital

 

 

 

 

 

 

 

Release

I authorize UCLA Health to release PHI to:

 

 

 

Records to

 

 

 

 

 

 

 

 

 

Where do

Name of Hospital/Clinic/Person: ________________________________________

you want

Address: __________________________________________________________

records

 

 

 

 

 

 

sent?

City, State & Zip Code: ______________________________________________

 

Phone: (

)_______________ FAX: (

)_______________

 

E-Mail Address: ____________________________________________________

Who do you

If you would like a designee* to pick up your records, please fill out section below:

want to

I authorize ________________________________ to pick up my medical record

receive

copies.

 

 

 

 

 

records?

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to patient: __________________

 

 

 

 

*Note: Designee must provide valid photo ID

 

 

Delivery

CD

E-Mail (NPH/BHS does not release via email)

Paper Copy

Instructions

Call Requestor when records are ready for pick up

 

 

(please

 

 

 

 

 

 

select one)

Note: If left blank, a CD will be provided.

 

 

 

Purpose

At the request of the patient/patient representative

 

 

What is the

Other (state reason)

 

 

 

 

purpose of

 

 

 

 

________________________________________________

 

this release?

 

 

 

 

 

 

 

Health

Type of Records:

 

 

 

 

Information

Medical Records

Mental Health (other than psychotherapy notes)

to be

 

 

 

 

 

 

Billing Statements

Emergency Reports (ER)

Pathology Reports

Released:

 

 

 

 

What

Consultations

History & Physical Exams

Progress Notes

records are

 

 

 

Discharge Summary

Jules Stein Images

Radiology Images

being

 

 

 

 

 

 

EEG Video

Laboratory Reports

 

(x-rays)

requested?

 

EKG

 

Operative Reports

Radiology Reports

 

 

Other:

UCLA Form #30910_ (Rev 12/19)

Page 1 of 2

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

MRN:

Patient Name:

(Patient Label)

 

Sensitive

Sensitive information will not be released unless specifically authorized

 

Information

 

below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drug and Alcohol Abuse Results

Genetic Testing Information

 

 

HIV/AIDS Test Results

 

 

Psychological/Vocational Results

 

Specify

SPECIFY DATE / TIME PERIOD FOR INFORMATION SELECTED ABOVE:

 

Date/Time

 

FROM MM / DD / YYYY TO MM / DD / YYYY

 

Period

 

 

 

 

 

 

 

 

 

 

 

Expiration of

Unless otherwise revoked, this Authorization expires __________________ (insert

 

Authorization

applicable date or event).

 

 

 

 

 

 

 

 

If no date is indicated this Authorization will expire 12 months after the date signed.

 

 

 

 

 

 

 

 

 

 

 

Signature(s)

 

 

 

 

 

 

 

 

 

 

__________________________________________

_____________________

 

 

 

(Signature of Patient / Legal Representative)

Date

 

 

__________________________________________

_____________________

 

 

 

Printed Name

 

 

 

 

Area Code/Phone Number

 

 

If signed by someone other than the patient, indicate relationship to the

 

 

patient ____________________________________

 

 

 

 

__________________________________________

_____________________

 

 

 

Signature of Witness (only if patient unable to sign)

Date

 

 

or Interpreter | Interpreter ID #_____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Addresses

 

 

 

 

 

 

 

Please check box for medical records

 

Please check box for radiology images

 

 

UCLA HIMS, Release of Information

 

Image Management, Release of Information

 

 

10833 Le Conte Ave, CHS BH-902

 

200 Medical Plaza

 

 

Los Angeles, CA. 90095-1776

 

B1- Level | Suite 165-11

 

 

Fax: (310) 983-1468 | Phone: (310) 825-6021

 

Los Angeles Ca. 90095

 

 

Email: roi@mednet.ucla.edu

 

Fax 310-825-3205 | Phone 310-825-6425

 

 

Please check box for mental health records

 

 

 

 

 

Mental Health Records

 

 

 

 

 

 

 

RNPH/BHS HIMS

 

 

 

 

 

 

 

10833 Le Conte Ave BH239A

 

 

 

 

 

 

 

Los Angeles CA 90095

 

 

 

 

 

 

 

Fax 310-206-7682 | Phone 310-267-2661 or 310-794-1530

 

 

 

 

 

Release of Information Customer Service – Walk-in Service

 

 

 

Open Hours

 

Ronald Reagan UCLA: 100 Med Plaza, Suite 140, Los Angeles, CA 90095

 

 

8a-4:30pm

 

Phone: (310) 825-6021 |

Fax: (310) 983-1468 |

Email: roi@mednet.ucla.edu

 

 

Closed Lunch

 

Santa Monica UCLA: 1260 – 15th Street, Suite 802B, Santa Monica, CA 90404

 

 

11:30a-12:30p

 

Phone: (424) 259-8045 | Fax: (310) 983-1468 |

Email: roi@mednet.ucla.edu

 

UCLA Form #30910_(Rev 12/19)

Page 2 of 2

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

MRN:

Patient Name:

(Patient Label)

COMPLETING AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

To protect our patient’s confidential medical information we must have a valid, complete and legible authorization to disclose their health information.

All sections of this authorization must be completely filled out before UCLA Health is permitted to disclose your protected health information.

Notice

UCLA Health and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

Revocation

I may revoke this authorization at any time, provide that I do so in writing and submit it to:

UCLA Health

Health Information Management Services

10833 Le Conte Avenue, CHS BH-902

Los Angeles, CA 90095-7305

The revocation will take effect when UCLA Health receives it, except to the extent that UCLA Health or others have already relied on it.

My Rights

I understand this authorization is voluntary. Treatment, payment enrollment or eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for:

1)conducting research-related treatment,

2)obtaining information in connection with eligibility or enrollment in a health plan,

3)determining an entity’s obligation to pay a claim, or

4)creating PHI to provide to a third party.

I am entitled to receive a copy of this Authorization.

UCLA Form #30910_(Rev 12/19)

- NOT PART OF THE LEGAL MEDICAL RECORD -

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1. You will need to fill out the ucla medical reports accurately, hence take care when working with the areas that contain all these blanks:

Ways to fill out ucla release records step 1

2. Your next stage is to complete all of the following blank fields: Where do you want records sent, Who do you want to receive records, Delivery Instructions please, City State Zip Code, Phone FAX, EMail Address, If you would like a designee to, I authorize to pick up my medical, Relationship to patient, Note Designee must provide valid, EMail NPHBHS does not release via, Paper Copy, Call Requestor when records are, Note If left blank a CD will be, and Other state reason.

ucla release records completion process explained (part 2)

3. The following portion is mostly about Delivery Instructions please, Mental Health other than, Type of Records Medical Records, Radiology Images, xrays, Radiology Reports, UCLA Form Rev, and Page of - fill out all these blank fields.

Completing part 3 of ucla release records

4. This next section requires some additional information. Ensure you complete all the necessary fields - AUTHORIZATION FOR RELEASE OF, MRN Patient Name, Patient Label, Sensitive Information, Specify DateTime Period Expiration, Signatures, Sensitive information will not be, Genetic Testing Information, FROM MM DD YYYY TO MM DD YYYY, Unless otherwise revoked this, Signature of Patient Legal, and Printed Name Area CodePhone - to proceed further in your process!

FROM MM  DD  YYYY TO MM  DD  YYYY, MRN Patient Name, and Signature of Patient  Legal inside ucla release records

As for FROM MM DD YYYY TO MM DD YYYY and MRN Patient Name, be sure that you review things in this current part. Both of these are viewed as the most significant fields in this PDF.

5. The very last stage to submit this document is pivotal. Be sure you fill out the appropriate blank fields, particularly If signed by someone other than, patient, Signature of Witness only if, Mailing Addresses Please check, and Please check box for radiology, prior to using the file. In any other case, it could result in an unfinished and probably invalid document!

patient, Signature of Witness only if, and Mailing Addresses  Please check inside ucla release records

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