Media Authorization Form
To comply with patient confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) guidelines, UCI Health requires a signed consent form before interviewing or photographing any patients, or before speaking to a physician in reference to that patient's care.
Please download and fill out the media release form, fill out the areas highlighted in yellow, then email your completed copy to firstname.lastname@example.org.
How to download: Right-click the link and select "save link as." Save it in a location where you are able to find it.