ember InformationMemberName ember Idon Id CardDate of BirthPhoneMember Address Providingyouris voluntarybut helpfulto accuratelyidentifyyourmedicalsupplying t ID: 893989
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1 AUTHORIZATION FOR DISCLOSUREPROTECTEDHEA
AUTHORIZATION FOR DISCLOSUREPROTECTEDHEALTH INFORMATION ember Information MemberName ember Id(on Id Card) Date of BirthPhone Member Address Providingyouris voluntary,but helpfulto accuratelyidentifyyourmedical supplying the last four digits is also an option InformationbeDisclosed request and authorizeUniversity of Utah Health Plansto DISCLOSEmy protected health information: Pleasecircle indicateyourselection/Full Record OtherPlease indicate: RecipientInformation authorizethefollowingperson(s) or organization to accessmember information: Name:Relationship: Pleaseindicatethepurposethe disclosureof yourmember records: This authorization expires (circle one) One time disclosureOne Year applicable,understandthatbased ontheinformationhavedesignatedabove;thedisclosuremakespursuantthis authorizationmayincludeinformationregardingparticipationin asubstanceabusetreatmentprogram.understandthattheauthorizedrecipientthisinformation SignatureDate Applicable,PrintedNamePersonalRepresentative Descriptionof PersonalRepresentativeAuthority:Parent Power of Attorney (attach documentation)Other (attach documentation) Return completed forms to UUHP Mail: PO Box 45180, SLC UT 84145 Email:uhp@hsc.utah.edu Fax: 801281