• UCLA Health
  • myUCLAhealth
  • School of Medicine
UCLA Health

UCLA Health
  • About Us
    • What is UCLA Health?
    • Our Leadership
    • News Releases
    • Awards & Achievements
    • Business Strategy
    • Connected Health/Telehealth
    • Industry Relations
    • Innovation & Technology
    • Quality & Service
    • ValU Care Redesign
    • Your Feedback
    • UCLA Health Careers
    • Volunteering at UCLA
    • Giving to UCLA
    • UCLA in the Community
    • Sound Body Sound Mind
    • Sustainability
    • Environmental Health and Safety
    • Celebrating Our Staff
    • Get Social
    • Mobile Apps
    Linked Graphic: Subscribe to Health Newsletters Vital Signs
    • Contact
    • Privacy Practices
    • Our Leadership
    • Awards and Achievements
    • News Releases
    • Medical Breakthroughs
    • Accountable Care Organization
    • Business Strategy
    • Industry Relations
    • Administrative Departments
    • In the Community
    • Lakers
    • Social Media
    • Take a Virtual Tour
    • UCLA Health Apps
    • Emergency Preparedness
    • Prescription for Excellence
    • Celebrating Our Staff
    • Innovation & Technology
    • Your Feedback
  • Conditions & Treatment
    • Health Library
    • Tests & Procedures
    • Drug Interaction Checker
    • Brain & Nervous System
    • Cancer
    • Children's Health
    • Heart Disease
    • Nutrition & Wellness
    • Pregnancy & Newborns
    • Orthopedics
    • Women's Health
    • Video Library
    • Cancer
    • Cardiovascular
    • Chiropractic
    • Cosmetic Surgery
    • Ear, Nose and Throat
    • Gastrointestinal
    • General Healthcare
    • Neurological
    • Obstetrics/Gynecology
    • See all videos...
    Symptom Checker
    • Video Library
  • Locations

    Hospitals

    • Ronald Reagan UCLA Medical Center
    • UCLA Medical Center, Santa Monica
    • UCLA Mattel Children's Hospital
    • Resnick Neuropsychiatric Hospital
    • Take a Virtual Tour

    Medical Offices/Clinics

    • Primary Care
    • Specialty Care
    • Urgent Care Centers
    • Outpatient Surgery Centers
    • Imaging/Radiology Locations
    • Coming Soon

    Others

    • Clinical Labs
    • Pharmacies
    • Institutes and Centers
    • UCLA Hospitals
    • Primary Care Practices
    • Specialty Care Practices
    • Urgent Care Centers
    • Outpatient Surgery Centers
    • Other Locations
    • Coming Soon!
  • Medical Services
  • For Patients & Visitors
    • Directions & Parking
    • Appointments: Call, Click, Come In
    • Admissions Information
    • Preparing For Surgery
    • Patient Services
    • Security & Parking Services
    • Office of the Patient Experience
    • For International Patients
    • Lodging & Nearby Services
    • Around Westwood
    • Gift Shops & Flowers
    • Health Resources
    • Log in to myUCLAhealth
    • About myUCLAhealth
    • Billing Information
    • Medical Records
    • Accountable Care Organization (ACO)
    • Covered California
    • Health Plans
    • Interactive Patient Education Videos (Emmi)
    • FAQs
    • Calendar of Events
    • Share your story. Connect. Share. Improve. UCLA Health
    • Share Your Story
    • Health Publications
    • Vital Signs Newsletters
    • Health Tips for Parents
    • Contact Us
    • Appointments: Call, Click, Come in
    • Admissions Information
    • Advance Directive
    • Covered California
    • Health Plans
    • Directions & Parking
    • Patient Services
    • Medical Records
    • myUCLAhealth
    • Smoke-Free
    • Publications
    • Health Resources
    • Around Westwood
    • Lodging
    • Preparing For Surgery
    • Patient-focused Technology Council
    • Health Forms
    • Frequently Asked Questions
    • Gift Shops
  • For Healthcare Professionals
    • Referring a Patient
    • E-Referral
    • Continuing Medical Education
    • Ethics Center
    • UCLA HealthLink
    • Physician to Physician Access Line (P2P)
    • David Geffen School of Medicine at UCLA
    • Clinical Informatics Fellowship
    • Academic Positions
    • UCLA School of Nursing
    • Department of Nursing

    Physician Publications

    • Physicians Update
    • Clinical Updates
    • U Magazine
    • E-Referral
    • Physician to Physician Access Line (P2P)
    • Clinical Informatics Fellowship
    • Flu Resources for Healthcare Professionals
    • Publications
  • Multimedia
    • UCLAMDCHAT Webinars
    • Community Health Program Videos
    • UCLAORLive Surgery
    • iTunes
    • Download Our Apps
    • Mini Med School
    • Demystifying Cancer Forum
    • TEDx UCLA Videos
    • Tips from our Physical Therapists
    • Patient Stories
    • Real Questions
    • Webinars on Demand
    • Pediatric Grand Rounds
    • Tune in to watch our health webinars
    • Community Health Program Videos
    • UCLAORLive Surgery
    • iTunes
    • UCLAMDChat Webinars
    • Download Our Apps
    • Mini Med School
    • Demystifying Cancer Forum
    • TEDx UCLA Videos
    • Tips From Our Physical Therapists
    • Patient Stories
    • Real Questions
    • Back Pain Management
  • Find a Provider
  • UCLA Health
  • myUCLAhealth
  • School of Medicine

Privacy Practices

Privacy Practices

Privacy Practices

  • Authorization for Release of Health Information
  • Media and Promotional Materials Authorization
  • Request by Patient for Access to Protected Health Information
  • Authorization for Release of Health Information
  • Media and Promotional Materials Authorization
  • Request by Patient for Access to Protected Health Information
  1. Home
  2. About Us
  3. Privacy Practices
  4. Authorization for Release of Health Information

Authorization for Release of Health Information

Share this

The following forms require Adobe Acrobat Reader. (Download)

  • Authorization for Release of Health Information - English

  • Autorizacion para la Divulgacion de Informacion Medica - Spanish
Like Us on Facebook Follow Us on Twitter Subscribe to Our Videos on YouTube Follow us on Instagram Add Us to Your Google+ Circles Connect with Us on LinkedIn Follow us on Pinterest Follow us on Flickr Follow us on Sharecare
  • UCLA Health
  • School of Medicine
  • School of Nursing
  • UCLA Campus
  • Directory
  • Newsroom
  • Publications
  • Giving
  • Careers
  • Volunteer
  • Privacy Practices
  • Emergency
  • Smoke-Free
  • Terms of Use
  • Sitemap
  • 1-800-UCLA-MD1
  • Maps & Directions
  • Contact Us
  • Report Broken Links
Like Us on Facebook Follow Us on Twitter Subscribe to Our Videos on YouTube Follow us on Instagram Add Us to Your Google+ Circles Connect with Us on LinkedIn Follow us on Pinterest Follow us on Flickr Follow us on Sharecare

Sign in to myUCLAhealth