Get Application Form - University Of Utah Health Care - Healthcare Utah

This guide provides step-by-step instructions for completing the Application Form for University Of Utah Health Care. Follow these clear and concise guidelines to ensure your application is filled out correctly and submitted efficiently.

Follow the steps to successfully complete your application form.

1. Click ‘Get Form’ button to access the application form and open it in your browser.
2. Enter today's date in the designated field in the format MM/DD/YYYY.
3. Fill out the patient information section. Include your first name, middle initial, and last name in the specified fields.
4. Provide your complete mailing address, including street, apartment number (if applicable), city, state, and zip code.
5. Input your email address and telephone numbers in the respective fields. Indicate whether each number is home, work, or cell.
6. Fill in your date of birth and patient's age as required.
7. Indicate your sex and marital status by checking the appropriate box.
8. Select your race and ethnicity from the provided options.
9. Enter your social security number in the designated field.
10. Choose your primary language from the options provided.
11. Complete the emergency contact section by providing the name and telephone number of a contact person.
12. Detail your residence history for the previous two years. Include addresses and dates of residency.
13. In the work history section, indicate your current employment status and provide details about your current job.
14. Answer questions regarding your history in the mining industry if applicable.
15. Complete the patient statement section with any pertinent information about why you seek care.
16. Provide insurance information if applicable or indicate if you do not have health insurance.
17. Review the entire application for accuracy before submitting.
18. Save your completed form and either print it out or send it via fax to the specified number. Ensure you return it to the address provided in the application.

Take the next step in your healthcare journey by completing your application online today.