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Apostille from the Utah Lieutenant Governor's Office

HIPAA Authorization - Utah

Utah · Fillable PDF · Free

Federal privacy law (HIPAA) limits who doctors, hospitals, and insurers can talk to about you. This authorization lets the people you name receive your health information so they can help you. Federal privacy law (HIPAA) limits who doctors, hospitals, and insurers can talk to about you. This authorization lets the people you name receive your health information so they can help you.

Download HIPAA Authorization - Utah PDF · 3 pages. No account required.

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Who this form is for

  • For Utah residents and families: hipaa authorization.

What you'll need

  • Read the supplied packet before filling in its fields.
  • Follow this document's signing, identification, witness and filing instructions.

How to complete it

  1. Who and what (Page 1) Name the people who may receive your information and choose what may be released. Initial any specially protected records you want included.
  2. Sign before a notary (Page 2) Hospitals and insurers are more likely to accept a notarized authorization without question. Bring a current, government-issued photo ID.

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These forms are a free convenience, not legal advice. First Choice Mobile Notary & Apostille is not a law firm. Consult an attorney licensed in the relevant state for legal questions.

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