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Printable Form 4876-A Sunnyvale California: What You Should Know

For a faster response, please print Medical Records Authorization and include it with your electronic medical record. We need a signature to process and verify medical records in your possession. This form requires the patient to sign to indicate that he/she is aware that certain personal information may be accessed by the Federal Government. If the patient does not wish a copy of the Medical Records Authorization transmitted to them, please leave the area blank. If the patient's signature appears on the authorization, a copy of his/her Medical Record will be transmitted to your physician. If the signature appearing on the authorization appears to include the patient's initials, that data will be included in your Medical Records Authorization and mailed to the physician. Request Your Medical Records — UnitedHealth Group offers several options for your convenience. We have provided four options for requesting medical records from UnitedHealth Group. A. Personal information not required but requested The individual or family member requesting a copy of the Medical Records Authorization must provide a letter notifying the UnitedHealth Group that the physician wants to receive such records. A. Personal information not required but requested — Please call the UnitedHealth Group at or and provide the following information: The individual or family member requesting the Medical Records Authorization. Address where the individual or family member resides. Signature of the individual or family member and/or signature of physician confirming that the individual or family member is a qualified individual requesting the Medical Records Authorization. For UnitedHealth Group patients who do not desire to receive their medical records in the mail, and they do not desire the medical records to be sent by courier, please request a copy in person by contacting us at. A. Personal information required The individual requesting the Medical Records Authorization must provide all the information listed below to UnitedHealth Group by telephone or in person at: UnitedHealth Group Attn: Legal Counsel, P.O. Box 69065 San Antonio, TX 78257 UnitedHealth Group Attn: Attorney General, P.O. Box 2614 Dallas, TX 75242 Phone: If the individual needs assistance in completing the Personal Information Form, UnitedHealth Group will assist the individual, and make the necessary changes upon his/her request. Please contact UnitedHealth Group for more information.

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