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.

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