Release of Information

• Authorization for the Release of Health Information
• Authorization (Spanish)
• Authorization for the Release of Psychotherapy
• Request to Amend Protected Health Information
• Request for an Accounting of Disclosures
• Request for Special Restriction
• Statement of Disagreement

All forms are in Adobe PDF format. If you are unable to view the forms, use to button below to download the latest version of Adobe Acrobat Reader.

The authorization forms must be submitted to our department. The forms can be filled out at our location, mailed, faxed, or scanned and sent via email. Please use our contact information below.

Address:
UC Davis Health System
Health Information Management
Medical/Legal Release of Information Unit
2315 Stockton Blvd., Bldg #12
Sacramento, CA 95817
Map 

Fax: (916) 734-2126

Email: ROI@ucdmc.ucdavis.edu 

Front Desk Hours:

Monday-Friday 8:00A.M. - 5:00P.M.