Download the Release of Medical Information form here.
Please fill out all highlighted sections, including:
- Patient’s Name, Date of Birth, Address and Phone Number
- Facility Authorized to Release Information to:
- Records Released to you – write in “SELF”
- Records Released to another Provider or Facility – please fill in the Providers name, address, phone and FAX number.
- Health Information to be disclosed – include all dates of service, what type of records you want released (labs, x-ray, complete, etc.), why you need the information (treatment, insurance, personal),
- The Yes/No question is an authorization to release any sensitive information. Typically this should be marked yes if you require all of your information to be released.
- Patient’s or Authorized Personal Representative’s Signature – please sign, date and time.
- Leave the Witness Signature line and everything below it blank.
You will also need to include a legible copy of your driver’s license or your Official ID so we may verify your signature with your hospital record.
After downloading and filling out this form, please fax to 858-430-4615, mail to: Mountain West Medical Center, Attn: Health Information Management Department, 2055 N Main St, Tooele UT 84074, or email to [email protected]. If you have question, please call 435-843-3722.