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

Filling out the Print Application Clear Form is essential for accessing medical services through The Miners Hospital and Clinic at the University of Utah. This comprehensive guide will help you navigate through the form step-by-step, ensuring you complete it accurately and efficiently.

Follow the steps to complete your application smoothly.

1. Use the ‘Get Form’ button to access the application and open it for editing.
2. Begin by indicating whether you are applying for benefits from the Disabled Miners Trust Health Fund by checking the appropriate box.
3. Fill in your patient information, including your full name, today's date, address, telephone number, age, date of birth, sex, marital status, race, social security number, and primary language. Ensure that all information is complete and accurate.
4. Provide details about the responsible party, if applicable. If the responsible party is different from the patient, fill in their name, relationship to the patient, contact information, and address.
5. Complete the emergency contact section by providing the name, phone number, and address of a person to contact in case of an emergency.
6. Detail your residence history for the last two years, listing addresses along with the dates of residence.
7. State your current employment status, including whether you are working, what type of mining you have done, and the duration of your work in the mining industry.
8. For each mining employment, fill in the name of the mine, hire date, separation date, type and location of the mine, and job title(s) with descriptions.
9. Answer the patient statement questions regarding residency and employment in Utah's mines, and describe the nature of your injury or symptoms.
10. Provide insurance information if you have health insurance, including details for each insurance company, policy holder, and policy number. If mailing the application, remember to copy your insurance cards.
11. After ensuring all sections are complete, save your changes, download the form, and prepare to print or share it as required.

Complete your application online today to ensure timely access to necessary medical services.