New Patient Form

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Personal Information

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Medical Information

Check here if you are the holder

 

Medical Record Release Form

I,                                                                                  hereby authorize the release of information as indicated: 

My Healthcare Information I authorize disclosure of healthcare information related to my medical history, diagnosis, treatment, or prognosis to all inquiries or only to the following people or entities: 

I choose                                            on the ABN form. 

By signing this, I acknowledge and understand the Notice of Privacy Practice, Lifetime of Benefits, ABN, and Medical Record Release. 

Signature:                                                                                                 Date: 

 

_______I have read and agree to the Summary of Notice and Privacy Practices.

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South Ogden:

955 Chambers Street Suite 200  South Ogden, UT 84403 

Phone: 801-627-2122

Fax: 801-627-2125

Farmington:

473 W. Bourne Circle,  Suite 2  Farmington, UT 84025

Phone: 801-451-7500

Fax: 801-451-6966

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