Directory Results for ILMA 3TN - lifemarketsassociation to ILMA 3UT 10/08 Utah Authorization for the Use and Disclosure of Protected Health Information Name: Date of Birth: SSN: Date of Request: I authorize health care providers and entities who have provided medical treatment to me to release

ILMA 3UT 10/08 Utah Authorization for the Use and Disclosure of Protected Health Information Name: Date of Birth: SSN: Date of Request: I authorize health care providers and entities who have provided medical treatment to me to release