Records Transfer - Urology Centers of Alabama

Please complete the form below to authorize the transfer of your medical records. By submitting this form, you confirm that the information provided is accurate and that you consent to the transfer of your records as specified.

For assistance or questions regarding this form, please call 256-739-2885.

UCA Medical Record Transfer Consent Form

Patient Name(Required)

First Last

Date of Birth(Required)

Phone Number(Required)

E-Signature: By typing my name below, I confirm that this serves as my legal signature and indicates my agreement to the terms above.(Required)

First Last