Ucla 30910 Form – Fill Out and Use This PDF

The UCLA 30910 form is a crucial document for anyone needing to authorize the release of their medical records from UCLA Health facilities. This form covers the release of information from UCLA Health Hospitals and Clinics, Jules Stein Eye Institute, and Resnick Neuropsychiatric Hospital to specified recipients. Understanding how to properly fill out and submit this form ensures that your health information is shared securely and with your consent. Click the button below to learn more about how to accurately complete and submit your UCLA 30910 form.

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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.

Question	Answer
Form Name	Ucla 30910 Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	ucla medical release, ucla release form, ucla medical records form, ucla medical records

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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
	 Resnick Neuropsychiatric Hospital
Release	I authorize UCLA Health to release PHI to:
Records to	I authorize UCLA Health to release PHI to:
Records to
Where do	Name of Hospital/Clinic/Person: ________________________________________
you want	Address: __________________________________________________________
records
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
receive	copies.
records?	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	 Other (state reason)
purpose of	________________________________________________
this release?	________________________________________________
this release?
Health	Type of Records:
Information	 Medical Records		 Mental Health (other than psychotherapy notes)
to be
to be	 Billing Statements		 Emergency Reports (ER)		 Pathology Reports
Released:	 Billing Statements		 Emergency Reports (ER)		 Pathology Reports

What	 Consultations		 History & Physical Exams		 Progress Notes
records are
records are	 Discharge Summary		 Jules Stein Images		 Radiology Images
being
being	 EEG Video		 Laboratory Reports			(x-rays)
requested?	 EEG Video		 Laboratory Reports			(x-rays)
requested?	 EKG		 Operative Reports		 Radiology Reports
	 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
Information	below:
	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		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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Ucla 30910 Form – Fill Out and Use This PDF

Ucla 30910 Form PDF Details

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