University Hospital

Medical Records Request & Release of Information

Patient Authorization Form

Release of information must comply with State and Federal guidelines. Please contact Health Information at (801) 581-2704 between the hours of 8am – 4:30pm Monday through Friday if you have questions regarding the release of patient information.

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

  • Patient name, Date of Birth, contact information and last 4 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 1 year, (signature must be notarized or witnessed by a University of Utah Healthcare employee)

For direct patient care questions please call (801) 581-2353.