Patient Forms
Below you’ll find forms that may be applicable to your primary or specialty care appointment or procedure. Complete and return them as requested by your care team before your UW Medicine hospital or clinic visit.
General UW Medicine
Medical records and authorization forms
- Notice of Privacy Practices Acknowledgment
- Patient Authorization for UW Medicine to Use or Disclose Protected Health Information for Publicity
- Patient Authorization to Disclose, Release and/or Obtain Protected Health Information
- Patient Authorization to Use and Disclose Protected Health Information for Publication
- Patient Authorization to Use or Disclose Photography/Video
- Request to Consider Additional Privacy Protection for Protected Health Information
- Request for Correction or Amendment of the Medical Record
- Request to Restrict Disclosure of Healthcare Items or Services to Health Plans When Patients Self-Pay Out of Pocket
Specialty care
Kidney transplant forms
- Alcohol and substance abuse agreement
- Dental clearance for kidney pre-transplant evaluation
- Kidney pre-transplant patient agreement
- Race and ethnicity data collection tool
- Patient demographic information - kidney/pancreas
- Patient health assessment - kidney/pancreas
- Transplant services blood pressure record