We’ve included a variety of forms that define your relationship with the Ear, Nose and Throat Center and allow you to control use and disclosure of your personal health information. Please call 801-328-2522 with any questions.
- Patient_Authorization_Form.pdf - This is your HIPAA medical records release form. This form allows you to authorize the use or disclosure of your protected health information.
- PCT_form.pdf - This document outlines the financial agreement between you and the Ear, Nose & Throat Center and also covers your consent for treatment by the Ear, Nose & Throat Center staff and physicians.
- Privacy_Practices_Form.pdf - This form allows you to state in writing that you have been provided a copy of Privacy Practices Notice Form.
- Privacy_Practices_Notice_Form.pdf - This document outlines our privacy practices. It is also available by clicking the "Privacy" link on this web site.
- Request_for_Amendment_Form.pdf - This form allows you to request that your medical record is changed.
- Request_for_Restriction_PHI_Form.pdf - This form allows you to state in writing that you do not want your medical records to be disclosed or shared with certain stated parties.
All documents are stored in the Adobe Portable Document Format. Click Here to download a free reader.
