How to Fill Out and Submit the UCLA Medical Records Release Form

To request your records from UCLA Health, download the Authorization for Release of Health Information form from the UCLA Health medical records page, fill it out, sign it by hand, and send it to the Health Information Management Services (HIMS) office by email, fax, mail, or in person. Most requests are completed within 15 days. If you already use myUCLAhealth, you can pull many records straight from the portal without submitting a paper UCLA medical records release form at all.¹

Where to Get the Form

The form is a single-page PDF on the UCLA Health medical records page. The same form covers both requests for your own records and third-party releases to another doctor, an insurer, or an attorney. If you prefer paper, you can pick one up at any UCLA Health facility’s medical records desk. Read it before signing. HIMS returns unsigned or incomplete forms without processing them.¹

How to Fill It Out

Your Identifying Information

Enter your full legal name and date of birth. The medical record number (MRN) field is optional, but adding it helps staff locate your files faster, particularly if you’ve been seen at more than one UCLA facility.² Your MRN shows up on visit summaries, billing statements, and inside myUCLAhealth.

Which Records You Want

Check only the record types you actually need. A narrower request moves faster. Available categories include clinic visit notes and consultations, discharge summaries, laboratory reports, radiology reports and images, operative reports, pathology reports, history and physical exams, emergency reports, EKG and EEG video, and billing statements. An “Other” field lets you add anything not listed, and you can either request your entire record or limit it to specific dates of service.²

The Sensitive Information Section

Four categories carry extra privacy protection and will not be released unless you check them individually in the separate “Sensitive Information” section:

Drug and alcohol abuse results
HIV/AIDS test results
Genetic testing information
Psychological and vocational results

Skip these boxes and UCLA Health will process the rest of your request but withhold anything in these categories.² Mental health records from the Neuropsychiatric Hospital and Clinic have their own separate checkbox.

Recipient and Purpose

Enter the full name, mailing address, and phone number of whoever should receive the records. If the records are for you, you are the recipient. For a release to a new doctor, a law firm, or an insurer, put their contact information here. The purpose field accepts entries like “continuing medical care,” “personal use,” “legal proceedings,” or “insurance claim.”

Expiration Date

Every authorization needs an expiration date or a triggering event, such as “upon conclusion of my insurance claim.” If you leave the expiration field blank, the authorization automatically expires 12 months after the date you sign.² You can revoke the authorization in writing at any time before it expires.

Signature

Sign and date the form by hand. UCLA Health does not accept electronic signatures at this time.¹ If a personal representative is signing for the patient, proof of that authority (a power of attorney or court order) must accompany the form.

How to Submit the Signed Form

HIMS accepts the completed authorization four ways:

Email: Scan or photograph the signed form and send it to roi@mednet.ucla.edu.
Fax: 310-983-1468.
Mail: UCLA Health, Health Information Management Services, 10833 Le Conte Ave., CHS, BH-902, Los Angeles, CA 90095.
In person: Drop it at a UCLA Health medical records desk. Staff can confirm receipt, but records are not handed over on the spot.¹

If you have a myUCLAhealth account, you may be able to request records directly through the portal and download them electronically at no charge, skipping the paper form entirely.¹

The HIMS office is open Monday through Friday, 8:00 a.m. to 4:30 p.m. For questions about a pending request, call 310-825-6021.

Imaging Studies Follow a Different Path

MRIs, CT scans, PET scans, ultrasounds, and DEXA scans go through UCLA Health Radiology, not HIMS. You can request a CD in person at most UCLA Health Radiology locations by showing valid ID and completing a release form on-site.³

For mail or electronic transfer, use the same Authorization for Release of Health Information form, but fax it to 310-825-3205 or mail it to the Image Management office. Describe the study clearly: type of scan, approximate date, body part. One extra step matters here. After you fax or mail the form, call the Imaging Library at 310-825-6425 to validate your request. The library will not process it until that phone confirmation happens. Mailed or faxed requests typically take 7 to 14 business days.³

If someone else is picking up your images, name that person on your authorization form. They will need to show ID and sign at pickup.³

How Long It Takes and What It Costs

California law requires healthcare providers to deliver copies of requested records within 15 days of receiving the request.⁴ If HIMS needs clarification or your form is incomplete, the clock essentially restarts once you resubmit.

The first 15 pages of paper copies are free. Additional pages cost 10 cents per page, plus postage if mailed. Records delivered by email or through myUCLAhealth are free. When records are too large to email, UCLA Health sends them on a CD at an average cost of about $5.50. You are invoiced by mail or email after the records are produced.⁵

You pick the delivery method on the form itself: myUCLAhealth portal, email, CD, or paper copies by mail. If you ask for an electronic format and the records can be produced that way, the provider must honor your choice.⁶

Requesting Records for Someone Else

A Minor Child

A parent or legal guardian generally qualifies as a minor child’s personal representative and can request their records. Narrow exceptions apply. If the minor lawfully consented to care on their own, which is common for reproductive health services, substance abuse treatment, and certain mental health care, or if a court has appointed someone else to make medical decisions, the provider may withhold records tied to that specific episode. You still have access to the rest of the record. If HIMS denies part of a request for your child’s records, ask which exception applies.

A Deceased Patient

The personal representative of a deceased patient, usually the executor or administrator of the estate, can authorize release. Under HIPAA, that right lasts for 50 years after the date of death.⁷ Submit the standard authorization form along with proof of your authority, such as letters testamentary or a court order appointing you. UCLA Health may ask for additional verification before releasing anything.

If You Need to Fix an Error in Your Records

Spotted a wrong medication, incorrect allergy, or misrecorded date? You can request a correction using a separate form, the Request to Amend Protected Health Information (PHI) Form, available on the same medical records page. The myUCLAhealth portal also accepts amendment requests, but currently only from a desktop computer, not a mobile device.¹

An amendment request is not a guaranteed change. The provider reviews it and may deny the request if, for instance, the information originated with another source or the provider believes the record is already accurate. If your request is denied, you can submit a written statement of disagreement that becomes a permanent part of the record.

1
UCLA Health. Medical Records: Release Form & FAQs
2
UCLA Health. Authorization for Release of Health Information
3
UCLA Health. Request a Copy of Your Imaging Study
4
California Legislative Information. California Code Health and Safety Code 123110 – Patient Access to Health Records
5
UCLA Health. Frequently Asked Questions – Release of Information
6
California Legislative Information. Health and Safety Code 123110
7
U.S. Department of Health and Human Services. Health Information of Deceased Individuals