Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.
Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés.
For your convenience, the complete English version of this form is attached below the Spanish version.
Medical Authorization Form Ct In Salt Lake - Authority for Release of Medical Information
Category:
State:
Multi-State
County:
Salt Lake
Control #:
US-00426
Format:
Word
Instant download
Description
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Patients can request their records through MyChart. Expedited requests will be completed in 72 hours and standard requests will be completed in 15 calendar days when all required documentation is received.To provide better patient care and to avoid delays, submit a fully completed form and complete clinical documentation. Please complete the Authorization to Disclose Medical Records Form and return it to Utah State Hospital for processing. For patients: Use our secure patient website to authorize release of your records. For providers: Use our secure provider website to request patient records. The patient portal provides quick access to a limited set of your health record at no cost to you. Patient access to medical records -- Third-party access to medical records -- Medical records services -- Fees -- Standard form.