The New Patient Information Form provides us with the information needed to set up a new patient chart and establish your billing account with Park City Clinic. Please complete this form as accurately as possible. The requested information includes demographics of each patient (name, age, address, date of birth, etc.) responsible party for payment, and any health insurance information that will help us to accurately bill your insurance company. This form is required for all new patients to Park City Clinic.
The Authorization for Release and Disclosure of Protected Health Information form is required whenever you request for your medical records at Park City Clinic to be transferred to another provider or facility. This form requires your signature. Once completed, please mail or deliver to the office where your medical records are kept.