UCA Medical Record Transfer Consent Form - Braswell Patient Name(Required) First Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone Number(Required)Authorization(Required) I authorize Urology Centers of Alabama (UCA) to transfer my medical records to Decatur Morgan UrologyAcknoledgement(Required) I understand this consent is valid for 12 months and can be revoked by written request. UCA is not liable for any issues arising from this transfer.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
