Med Rec/Radiology Release

Authorization Please release the medical records of: Last name, first name Birthdate Student ID # Telephone To: Name Address City, State, Zip Restrictions Please release the following: (Check one) All Medical Records Clinical Notes Only HIV test results (Specify) Yes No Lab / X-ray Reports Only Restrict to the following dates/conditions: Restrict to information necessary to complete form provided X-ray Film Copy(ies) Other (specify) Purpose Disclosure is for the following reason(s): Check as many as apply Personal Records Continued medical

care Other specify Unless otherwise specified below, this Authorization is valid for 30 calendar days after today. If not 30 days, this Authorization is valid until It is prohibited by law to release/disclose the attached/enclosed information to anyone except those specified above. I understand that this Authorization alone may not authorize release of psychiatric or HIV information. Patient’s Signature Date Witness’ Signature Date Witness’ Printed Name Mail Pick-up Done - given to student June 2007 Box 951703 / Los Angeles, CA 90095-1703 Including HIV Info Authorization to Release Information from the Medical Record / Radiology Insurance claim Legal action Service Request Fee Chart photocopy (110) Insurance application (112) Record search and review (110) Subpoena (111) X-ray film copy, 1st film (136) Addl.copies, # (137) $2 ea. Other, specify Yellow copy given to requestor If you are a currently registered student charges will automatically be billed to BAR Checks may be written, payable to Regents, UC Check Attach this form with check for acccounting after scanning BAR Total Due: Signature $5.00 U C L A Arthur Ashe Student Health and Wellness Center...

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