WPCe 6y.ck>_#3戼?V{|z} YNUV 1YyF5~͉Ե;6ww*9tҭmCid6F|e099.zڜ>sU(Iq_^ħ~!тOr +H a{k]><=,)gy\!ʇ0uy gSfz-E=UK/3a0+/( ӻ#ʢ3uEK8'|/Ho c)/-};N4+ҟe$.ڭ,G̯h{qB-XERoҡp7Ei;'xI9EzF81B!UQ |J\򭤞+:~T'QqN>)#!>UN_ % 0(U:faf+a-fAaCw@W4fafafa^  mN))))))) B+++++ BH\\UTSTDP01\ARCHIVES-HP4SI-2,,^^,,0(hH  Z 6Times New Roman RegularX($,  AZ"Arial RegularTABLE ATABLE BTABLE C ;<U=D>D?BCE GH@E'3|xHTABLE DTABLE ETABLE F1o'cU d  d !  _XXXX|nXXXG@#  RECORDSREQUEST  X CXX|nGB*#ddd Xdd Xdd X%%,"dd +  (((  RequestersName:򀀀 @ Address:򀀀 | ̀DaytimeTelephone:򀀀Date:򀀀    ( n  ((( (*e# dd"dd "#%%e,"dd +  ((  h  IfrecordsarefiledbySocialSecuritynumber,providethatnumber:򀀀󀄀򀀀󀄀򀀀   InaccordancewiththeGovernmentRecordsAccessandManagementAct,Iamrequestingto_____View_____Copythefollowingrecord(s),describedspecificallyas:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________WhichIbelievearecollected,filed,and/orusedbythefollowing:______________________________________________________________________________________________@# NameofAgency______________________________________________________________________________________________@# AgencyAddress______________________________________________________________________________________________Ifrequestedrecordsarenotpublic,explainwhyyoubelieveyouareentitledtoaccess:_____Iamthesubjectoftherecord_____Iamthepersonwhoprovidedtheinformation_____Iamauthorizedtohaveaccessbythesubjectoftherecordorbythepersonwhosubmittedtheπinformation.DocumentationrequiredbyUCA63!2!202,isattached. # ) _____Other(explain)____________________________________________________________________________Signature:_____________________________________________________________________________________(.&#- (( (*e # dd"dd "# %%e,"dd +  ((( ('$- Ifrequestedrecordsareclassified Controlled,signthefollowing:@# ACKNOWLEDGMENTIherebyacknowledgethatIamaphysician,psychologist,certifiedsocialworker,insuranceprovideroragent,andthatIwillnotdisclosecontrolledinformationtoanyperson,includingthesubjectoftherecord,exceptinresponsetoalawfulorderoftheStateRecordsCommitteeorthedistrictcourt. H,)4 ___________________________________________________________________________________________̀SignatureDate(p/-8 ((( (BG  X X|nXCGE@YY"  NOTICEOFDENIAL EG#CXX|n7#GE X *#ddd Xdd Xdd X%%,"dd +  C ((((  CEC ((((  ЀDate:__________________________________________Yourrequestforthefollowingrecordsorportionofrecordshasbeendenied:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Theserecordsareexemptfromdisclosurebythefollowing:̀Courtorder:________________________________________________________________________________̀Statute:___________________________________________________________________________________@& CitationYouhavetherighttoappealthedenialtothechiefadministrativeofficer(UCA63!2!205(2)(c)(1992)).Anoticeof t appealmustbesubmittedwithin30days.Yournoticeofappealmustincludeyourname,mailingaddress,adaytimetelephonenumber,andexplanationofwhatreliefyouareseeking.Anysupportinginformationshouldalsobeincluded.Thisshouldbesenttothefollowing:ChiefAdministrativeOfficer:______________________________________________________________________BusinessAddress:______________________________________________________________________________̀______________________________________________________________________________̀______________________________________________________________________________̀ThankYou,_____________________________________̀SignatureofagencyrepresentativeCE(v (((( (ECX|nXC@SS!  FORAGENCYUSEONLY #CXX|n#Ԉ D % CE*e#dd"dd "#%%e,"dd +  C (((( p CEC (((( p Requestreceived:_______________________Personreviewingrequest:___________________________________Howistherecordseriesclassified?_____Private,UCA63!2!302 $h"+ _____Controlled,UCA63!2!303 %2#, _____Protected,UCA63!2!304 T&#- _____Exemptorgovernedbyanotherstatute,UCA63!2!201(3)(b)________________________________________ '$. Ifrecordsarenotpublic,howwasidentificationverified?________________________________________________________________________________________________________________________________________________Copyingfee(s):__________________________________________________________________________________Responsedates:̀Requestapproved:_________________________________Recordssent:____________________________̀Requestdenied:_________________________________Denialsent:____________________________̀Notifiedrequesterrecordsnotmaintainedbythisagency:___________________________________________̀Extraordinarycircumstanceextensiontime:__________________________Sent:_______________________CE(| (((( (EG  X X|nXCG@  CONSENTFORTHERELEASEOFINFORMATIONTOATHIRDPARTY G#CXX|n #G X HCXX|nH*#ddd Xdd Xdd X%%,"dd +  ; ((((  ;;   ;I,_____________________________________________________________________________________________@ Nameofindividualauthorizingreleaseauthorize_______________________________________________________________________________________@ Nameofagencyholdingrecordtoreleasethefollowinginformation__________________________________________________________________̀Titleofseries,filegroup,ordescriptionofinformation<<_______________________________________________________________________________________________@  * _______________________________________________________________________________________________@  * towhom____________________________________________________________________________________________Iamthesubjectoftherecord(s)_____Iamthelegalrepresentativeofthesubjectoftherecord.Documentationattached.Iunderstandthattheserecordsarerestrictedunderstateprivacylawsandcannotbedisclosedwithoutmywrittenconsent.Anotarizedreleaseshallnotbedatedmorethan90daysbeforetherequestismade.̀_____________________________________________________________________________________@ SignatureofindividualauthorizingreleaseExecutedthis_______________________dayof____________________________________________,19______.StateofUtah)̀)ss.Countyof>>??񀀀)E  ԍEH  ԍHHHEE=88=EEHH̀By_____________________________________________̀NotaryPublic,StateofUtah̀_____________________________________________̀Residingat̀_____________________________________________̀Mycommissionexpires(expirationdate)Subscribedandsworntobeforemethis_____________dayof________________________________,19________by___________________________________________,knownbymetobethepersonnamedabove.HHE  EH  H(/-: (((( (H#X|nXC7!#H