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Accounting of Disclosures

You have the right to request an accounting of certain disclosures of your health information made by us. The list does not include disclosures made for treatment, payment, and health care operations and some disclosures required by law. Your request must state the period of time requested for the accounting. An accounting goes back only six years and does not cover disclosures made prior to April 14, 2003. The first accounting is free but a fee will apply if more than one request is made in a 12-month period. Call the Health Information department at (801) 587-3887 or visit http://uuhsc.utah.edu/privacy on the Internet to find out how to do this.

To request an Accounting of Disclosures:

1.	Complete the Accounting of Disclosures Request Form, but do NOT sign it, yet. Click here for the form.
2.	Have the form notarized or the signature witnessed by a member of University Health Care. Click here to see our requirements for witness or notarization of your signature.
3.	Mail the form to: Health Information 50 N Medical Drive Salt Lake City, UT 84132

Please contact us if you have any questions: (801) 587-9241.