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


Information Release

Forms

  • University of Utah Health Care Patient Release and Authorization
  • Law Enforcement Release and Authorization (Note: Notarization not required if presented by a law enforcement officer.)

Health Care Patient Release and Authorization

Routine Requests for Release of Information

  1. If a patient wants to look at their medical record or get copies of their record, they may submit a written request to the Health Information Department.
  2. If the patient comes in person, they must bring government-issued, picture identification, e.g., driver’s license, passport, military card, etc.
  3. The patient must complete the ‘Patient Authorization to Disclose Protected Health Information’ form. Authorization Form to Disclose PHI
  4. A University Health Care staff member will sign the form as a witness to verify that the form is complete and the signature belongs to the person making the request.
  5. If the patients completes the form and send their request by mail, e-mail or FAX, the form must be notarized to verify that the signature belongs to the patient.
  6. If a third party (friends, family members, etc.) requests to see or copy a patient’s health information, they must either have the patient with them, and follow these instructions, OR they must present a notarized authorization signed by the patient to Health Information, and present government-issued, picture identification.
  7. Health Information has up to 30 days to respond to a request for records.

Law Enforcement Release and Authorization

Non-Routine Release of Information to Attorneys, Law Enforcement, or Administrative Agencies

  1. Patient Authorization for Release of Protected Health Information (PHI) - A notarized authorization, signed by the subject of the records, which identifies the specific records we are authorized to release. A valid release and authorization is available below. If the patient appears in person and presents identification, no notary is required. If the request is submitted by mail or FAX, the signature must be notarized to ensure verification of requestor identity.
  2. Court Order - An order of a court or administrative tribunal with jurisdiction to order records from the University, which identifies the specific records the University is required to release to you and imposes appropriate safeguards against unauthorized disclosure.
  3. Affidavit of Issuance of a Valid Subpoena AND Proof of Patient Notice and Time for Response* - A valid subpoena from a court of competent jurisdiction in Utah accompanied by a completed, notarized affidavit in the form available by clicking here, and a copy of the Notice in the form specified in the affidavit.
  4. Affidavit of Issuance of a Valid Subpoena AND Protective Order* - A valid subpoena from a court of competent jurisdiction in Utah accompanied by a completed, notarized affidavit in the form available by clicking here, and a copy of the Protective Order in the form specified in the affidavit.
  5. Patient Authorization for Release of Psychotherapy Notes - A separate, specific authorization is required for the disclosure of psychotherapy notes. These must be always be notarized. The University Psychotherapy authorization form can be found here.
  6. Release of Information to Prosecuting Attorneys - Utah Rule Criminal Procedure 14 - A prosecuting attorney may submit a subpoena under Utah Rule Criminal Procedure (URCP) 14 for a case that has been filed. If the records being requested are those of a victim(s) who are not also the defendant(s), one of the other process listed in this document must be followed. To expedite the processing of these subpoenas, please make sure to indicate that it is being submitted under URCP 14 and that a case has been filed.
  7. Affidavit of Proof of Child Abuse/Neglect Investigation* - If your request is pursuant to Utah Code § 62A-4a-406(3), APPEAR PERSONALLY and present your identification, or complete and notarize the "Child Abuse/Neglect Investigation Affidavit" available by clicking here.

* Note: Federal law prohibits the University from releasing substance abuse treatment records without a patient authorization directing us to release such records, or a specific court order. Without an authorization or a court order, the University cannot even disclose whether such records exist. See 42 CFR Part 2.

If you have questions, please contact the Health Information Department at (801) 581-2704. Many of these forms can be opened, filled in, and printed on-line.