Your Rights Concerning Your Health Information

YOU HAVE THE RIGHT TO:
Requests marked with a star (*) must be made in writing. (A form is provided for your convenience).

Receive a copy of our privacy notice.
Notice of Privacy Practices - English
Notice of Privacy Practices - Spanish


Receive a copy of your paper of electronic medical record.*
Patient Authorization to Disclose Protected Health Information form

  • This includes medical and billing records. Fees may apply. Under limited circumstances, we may deny access to a portion of your health information and you may request a review of the denial.


Correct your paper or electronic medical record.*
Patient Request to Amend Protected Health Information form

  • You may ask to correct health information about you that you think is incorrect or incomplete. Correction of our electronic medical record occurs by amending the record rather than deleting or erasing information.


Request confidential communication.*
Patient Request for Alternate Method of Communication form

  • You can ask us to use a different way, or telephone number or address to communicate with you. You may make this request in writing during registration


Ask us to limit the information we use and share.*
Patient Request for Special Privacy Restriction form

  • You can ask us NOT to use your health information for treatment, payment, or our operations. We are not required to agree with your request, and may decline if it will affect your care, or it is not feasible.


Ask us NOT to share certain health information with your insurer.*
Patient Request for Special Privacy Restriction When Self Pay form

  • If you pay for a service or health care item “out-of-pocket” and in full, you can ask us not to share that information with your health insurer. We will agree, unless a law requires us to share that information.


Get a list of those with whom we have shared your information for reasons other than treatment, payment, or administrative purposes.*
Patient Request for Accounting of Disclosures form

  • Your request must include a specific time period. The first accounting is free but a fee will apply if more than one request is made in a 12 month period.


Choose someone to act for you.*
Legal documentation of your choice is necessary.

  • If you have given someone medical power of attorney, or someone is your legal guardian, that person can make choices about your health information.

Contact Us

Phone: 801-587-9241
Fax: 801-587-9443

515 E 100 S
Suite 650
Salt Lake City, UT 84102