Medical Records Request

MEDICAL RECORDS DEPARTMENT

Jordan West Family Counseling 9263-B Redwood Road West Jordan, UT 84088
REQUEST DATE:

MonthDayYear
Date
All records request will be fulfilled according to Utah Code Title 78B Chapter 5 Section 618. There is a $20.00 search fee plus $0.50/page for the first 40 pages and $0.30 for pages over 40
Requestor's Name:

First NameLast Name
Client Information:

NameDate of Birth
Please list all records and date ranges.
Client Signature

Clear
Date

MonthDayYear
Date
State of enter state County of enter county The foregoing instrument was acknowledged before me this (date) by (person acknowledging, Title or representative capacity, if any).
(Signature of Person Taking Acknowledgment)

Clear
(Seal)
My commission expires:Residing at:
Confidentiality Notice The documents accompanying this facsimile transmission contain confidential, privileged information, belonging to the sender. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required by State law.

If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this facsimile in error, please notify the sender immediately to arrange for return of these documents.
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MEDICAL RECORDS DEPARTMENT