YOU MAY REFUSE TO SUBMIT THIS AUTHORIZATION
By submitting this form, you authorize the release of your Protected Health Information (PHI). Your authorization will remain in effect until revoked or expired. Authorization is not required for medical treatment or payment of your claims.
You may also print this form and mail or fax it to:
PO Box 161020
Salt Lake City, UT 84116-1020
A copy of a notarized Power of Attorney may be submitted to authorize this request. To revoke this authorization at any time, please click HERE for the revocation form.
If you have any questions, please contact the UP Health Member Services team at 800-547-0421, Monday through Friday from 7:30 a.m. to 3:30 p.m., MST (TTY/TDD call the national number 711).