Authorization for Use or Disclosure of Your Health Information

You have the right to request that we provide you a copy of your health information, send your health information to a third party (such as a life insurance company), or use your health information for a research project.

You also have the right to revoke an authorization that you previously signed, but the revocation will not have any effect on actions taken in reliance upon the original authorization. In other words, once we receive your revocation, we will stop using or disclosing your health information as you had previously authorized, but cannot retrieve information we already used or disclosed.

To request that we send your health information to a third party or to yourself:

1. Complete the Authorization 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
We will review your request and respond to you within 30 days and may request an extension, if necessary.

To revoke a previously signed authorization:

1. Complete the Authorization Revocation 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 the department you originally filed the authorization with; OR
write the name of the original department you filed it with on the form and mail the form to:

Health Information
50 N Medical Drive
Salt Lake City, UT 84132
We will review your request and implement the revocation within 30 days.


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