Medical Records Request
& Release of Information
Printable Charts Request Form [PDF] - staff use only
Patient Authorization Form
Release of information must comply with State and Federal guidelines. Please contact Health Information at (801) 581-2704 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 and Social Security Number
- 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 if request is mailed.)
Hospital staff may request medical records in person or over the phone. If completing the online Request Form please print and send to the Health Information Department at AA241 SOM or
fax to (801) 581-2177. Only authorized personnel may request a medical record and only for appropriate purpose such as:
- rendering patient care
- collection of accounts
- teaching functions
- research
- clinical pertinence
