MRRPatients

PATIENT INFORMATION *	REQUEST FOR MEDICAL RECORDS (Part 1)
Email *
YOUR FULL NAME: *
DATE OF BIRTH (mm/dd/yyyy) *
Phone Number *
Physical Street Address (Include Apt No.)
City *
State *
Postal Code *
PATIENT INFORMATION	PATIENT REQUEST FOR ACCESS (Part 2)
Provider Clinic Name: *	Marula Rehab Telehealth
Provider Address: *	2728 N. Canyon Road. Pleasant Grove Utah 84062
Provider Phone Number *	801-427-1062
PATIENT INFORMATION *	By submitting this form, I am requesting access to my medical and behavioral‑health treatment records maintained by the above provider under HIPAA, 42 CFR Part 2, and applicable Utah law.
GOVERNMENT ISSUED ID (Not Expired) *	Max file size (Mb): 20 Max number of files: 1
SECOND PIECE OF ID:	Max file size (Mb): 2 Max number of files: 1
REQUEST FOR VIDEO VERIFICATION	I DON'T HAVE A SECOND PIECE OF ID, PLEASE SCHEDULE A VIDEO VERIFICATION:
RECORDS REQUEST *	RECORDS REQUEST - (Part 3)
Select *	Complete Telehealth Medical Record Telehealth Visit Notes (Individual / Group / Family) SUD Treatment Records (42 CFR Part 2) Intake Assessment Biopsychosocial Assessment ASAM Assessment - Level of Care Treatment Plans Telehealth Attendance Logs (IOP/PHP) Medication / MAT Records Urine Drug Screens / Toxicology Discharge Summary & After Care Billing And Claims Records Court XChange Records (Criminal History) Other Records Not Listed (List Below)
Other Records Not Listed:
CONSENT TO RELEASE *	Consent to allow my personal access to my requested records
Today's Date: *
ACKNOWLEDGEMENT *	I understand and acknowledge that no portion of my medical, mental‑health, or substance‑use treatment records will be released, disclosed, transmitted, or made available to me or to any third party until the provider has completed legally required identity‑verification procedures. This verification requirement is mandated under: HIPAA Privacy Rule, 45 C.F.R. §164.514(h) (verification of identity and authority prior to any disclosure of Protected Health Information) HIPAA Security Rule, 45 C.F.R. §164.312(d) (person or entity authentication) 42 C.F.R. Part 2, §2.13 and §2.31 (strict identity verification before releasing Substance Use Disorder treatment records) Utah Code Ann. §26B‑8‑102 and §26B‑8‑103 (confidentiality of health records and verification prior to disclosure) Utah Administrative Code R432‑100‑33 (identity verification requirements for behavioral‑health and telehealth providers) Accordingly, no records—whether electronic, printed, telehealth‑generated, diagnostic, billing‑related, or Part 2‑protected—may be released until my identity has been confirmed through the provider’s approved authentication process, which may include government‑issued identification, multi‑factor authentication, secure patient‑portal verification, or other methods permitted under federal and Utah law.

Marula Rehab Telehealth

(HIPAA 42 CFR Part 2 Compliant — Telehealth‑Specific)