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

Application for Services The Miners Hospital and Clinic University of Utah Clear Form Print Application SECTION I Instructions for completing this form To be considered for medical service through The Miners Hospital or Clinic please complete this form and return to Or FAX the completed form to 801-585-0452. Date MM/DD/YYYY 7 of 8 INSURANCE INFORMATION 1. Do you currently have health insurance 2. If YES please provide the following information If.

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