ÈËÆÞÖгöÊÓƵ

ÈËÆÞÖгöÊÓƵ Care Patient Release & 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 ÈËÆÞÖгöÊÓƵ Information Department.
2. If the patient comes in person, they must bring government-issued, picture identification, such as a driver’s license, passport, military card.
3. The patient must complete the ‘Patient Authorization to Disclose Protected ÈËÆÞÖгöÊÓƵ Information’ form. Authorization Form to Disclose PHI.
4. A ÈËÆÞÖгöÊÓƵ of Utah ÈËÆÞÖгöÊÓƵ 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 patient completes the form and send their request by mail, email or FAX, the form must be notarized to verify that the signature belongs to the patient.
6. If a third party (friends, family members, other) 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. 

ÈËÆÞÖгöÊÓƵ Information has up to 30 days to respond to a request for records.

Law Enforcement Release & Authorization

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

1. Patient Authorization for Release of Protected ÈËÆÞÖгöÊÓƵ Information (PHI)—An 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. 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 ÈËÆÞÖгöÊÓƵ of Utah ÈËÆÞÖгöÊÓƵ, which identifies the specific records U of U ÈËÆÞÖгöÊÓƵ 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, affidavit in the form 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 affidavit in the form 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.
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 the Child Abuse/Neglect Investigation Affidavit.

*Note: Federal law prohibits ÈËÆÞÖгöÊÓƵ of Utah ÈËÆÞÖгöÊÓƵ 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, ÈËÆÞÖгöÊÓƵ of Utah ÈËÆÞÖгöÊÓƵ cannot even disclose whether such records exist. See 42 CFR Part 2.

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

How to Submit Patient Information Release Forms

The applicable form must be filled out for the release of health care information. For questions contact the health information office.