The Release of information Form (ROI) needs to be filled out by the Patient (or Guardian if patient is under 18) 

This form can be used to have United Community Health Center FAX any of the following forms:

-FMLA Forms 

-Medical Excuses for Jury Duty 

-Disability Long Term/Short Term 

-Tax Exception Forms

-Work/School Excuses 

-Work Status Letters/Forms 

-Immunizations to Colleges/Universities, Daycare or Preschool 

-Balance for Life- Physician Screening Forms to Employer 

-other documentation being faxed out to a non-medical institution. 

Or 

-Transfer of Care 

-If you as the patient or Parent needs records for Personal use 

(Please be advised that if you are requesting records for personal use this may incur a fee)

-Our third-party copy service (VRC) process all these requests.. for Updates on your request please call 520-202-5354

Please check all fields before submitting. If your form is filled out incorrectly, please expect a call from the Medical Records Department @ UCHC.

You can call UCHC Medical Records Department for help and information @ 520-407-5900 Ext 7607