Authorization for SLCoHD to Release Records
(HIPAA-covered Programs Only)
Submit completed form to HealthPrivacy@slco.org
I hereby authorize the disclosure of my protected health information (PHI) (or that of an un-emancipated minor for
whom I have legal authority) as described below. I understand that this authorization is voluntary and that any
information released may be subject to re-disclosure by the recipient and may no longer be protected by federal or
state law. I understand that requests require photo identification and may take up to 30 days to complete.
THIS AUTHORIZATION IS FOR RELEASE OF PHI FOR THE FOLLOWING CLIENT:
Name: ______________________________________________ Date of Birth: ___________________________
Address: ____________________________________________ Phone: ________________________________
City: ___________________________________________________State: ______ ZIP: ____________________
R
elease information from
(person/organization providing the PHI):
______Salt Lake County Health Department______
Release information to
(name or identifying information):
___________________________________________
Purpose of the disclosure:
Medical Care; Client Request; Other (specify): ______________________
PHI to be released (describe information): ________________________________________________________
__________________________________________________________________________________________
This authorization is limited to PHI created from ________________________ to _________________________.
I also understand that I may limit the information to be released by specifying only those records needed. I further
realize that if I authorize all of my records to be released, SLCoHD will follow my instructions to the extent allowed.
The client or the client’s personal representative must read and initial the following statements:
I understand that:
______ 1. I may revoke this authorization at any time with written notification to the Privacy Officer, Privacy
Coordinator or designee sent to the address on the back. If I do revoke, I understand that this
decision will have no effect on actions taken prior to receiving the revocation.
______ 2. My health care and payment for my health care will not be denied if I do not sign this form.
______ 3. This authorization expires on: _______________ or upon the occurrence of _________________.
______ 4. There may be a charge for complying with this request.
______ 5. I will receive a copy of this form after I sign it.
____________________________________________ ________________________ ________________
Signature of Client (or Personal Representative) Relationship to Client Date
Copies of PHI should be paid for and picked up in person. With prior arrangement, we may also mail or fax
(medical offices only). Please check below how you should receive the requested records (if by mail, confirm
address above):
Pick up in person; Certified mail (I will pay the cost); 1
st
class mail; Fax (number: ______________)
FOR OFFICE USE ONLY
Form of ID: __________________________________ USIIS Record Only: Y N N/A
ID verified by: ________________________________ Client ID/Chart #: ___________________________
Date request received: _________________________ Date processed: ____________________________
Employee releasing data: _____________________________________________________________________
