Medical Records & Information Release

Patient Authorization Form

Release of information must comply with state and federal guidelines. Please contact Health Information if you have questions regarding the release of patient information.

Contact
Phone: (801) 581-2704
Hours: 8:00 am–4:30 pm, Monday through Friday

A person requesting medical records must submit a written consent with the following information:

  • Patient name, date of birth, contact information and last four digits of your SSN
  • Information being requested and dates of service
  • The name and address of the person the information is being released to
  • The signature of the patient, signed within one year, (signature must be notarized or witnessed by a University of Utah Health Care employee)
 

Patient Care Questions
Phone: (801) 581-2353