Patient Forms

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_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.

Adobe Portable Document Format All documents are stored in the Adobe Portable Document Format. Click Here to download a free reader.

Patient Portal

8:00 am to 5:00 pm