Special Privacy Restriction

A special privacy restriction must be made in writing. You may request a special privacy restriction using the following procedure:


We will review your request and respond to you within 60 days.
1. Complete the Request for Special Privacy Restriction, 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: University Privacy Office:

650 Komas Drive Suite 102
Salt Lake City, UT 84108


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