Get Utah State Hospital Access To Records Request Form - Ush Utah

This guide provides clear and concise instructions for completing the Utah State Hospital Access To Records Request Form online. By following these steps, users can efficiently request access to their healthcare records.

Follow the steps to successfully fill out your records request form.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in your name at the top of the form, ensuring that you write it exactly as it appears in your identification documents.
3. Provide your Social Security number, which will help in identifying your records more accurately.
4. Enter your current address, writing it in the designated field on the form.
5. Include your date of birth to assist in verifying your identity.
6. Fill in your phone number, allowing the hospital to contact you if necessary.
7. Indicate whether you are requesting access to your healthcare information or copies of your records for a specified time period. Clearly state the start and end dates.
8. In the provided section, specify the type of information you are requesting from the following options: Discharge Summary, HIV/AIDS Related Information, Labs, etc. You may check multiple boxes if needed.
9. If applicable, complete the section for Guardian/Personal Representative if someone is completing the request on your behalf. They must sign and indicate their authority.
10. Sign and date the form to confirm your request. If a representative is filling it out, they must also provide their signature and authority information.
11. Review your form for accuracy. Once completed, save any changes, download the form, or print it to submit it to the Medical Records Department.

Complete your records request form online today for timely access to your healthcare information.