Medical Record Release Form - University of Utah Health Care - healthcare utah 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your name, medical record number, date of birth, and phone number. Providing your Social Security number is optional but can help identify your records.
3. Indicate the approximate dates of treatment you wish to disclose. This helps streamline the retrieval process.
4. Authorize the health care provider or facility that will disclose your information by selecting from the provided options such as University Hospital or Huntsman Cancer Institute.
5. Specify who will receive your patient information by filling in their names, relationships, addresses, and phone numbers.
6. Select the specific information you want disclosed by circling the relevant options like treatment plans or discharge summaries.
7. State the purpose for disclosing your records. You can check if it's for personal use.
8. Review and sign the authorization section, ensuring all necessary fields are completed before submitting.

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