Release of Information

This form is used to request that the client's personal and protected health records with Quality Youth Services be released to a third party or to the client, or both. This form can also be used in order for a third party to share their personal and protected health records for a client with Quality Youth Services. These forms are usually signed so Quality Youth Services can speak with a third-party regarding the client. Care is made to release only what is necessary to that third party or vice versa.

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877-393-6232 
Fax: 801 393-4081
admin@qyservices.com

QYS Clinical Services


2240 North Highway 89 STE C
Ogden, UT 84404

 
180 South 600 West 

Logan, UT 84321

140 South Main STE 1 & 2
Pleasant Grove, UT 84062

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