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

UCI Health media authorization form ›

Autorización para la relación entre los medios de comunicación y la comunidad ›

How to download: Right-click the link and select "save link as." Save it in a location where you are able to find it.

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