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Get Ut Individual Clearance For Direct Patient Access Application 2012-2024

0) 662-4157 toll free (801) 538-6163 Fax INDIVIDUAL CLEARANCE FOR DIRECT PATIENTACCESS APPLICATION Version: May 2012 (All fields must be complete or form will be returned) APPLICANT INFORMATION Print Form (Information must be completed by the applicant - Print legibly in black ink or type) Male LAST NAME FIRST NAME MAIDEN NAME & ALL PREVIOUS MARRIED NAMES/ALIAS MIDDLE NAME Female GENDER DATE OF BIRTH DRIVERS LICENSE NUMBER SOCIAL SECURITY NUMBER STATE CURRENT ADDRESS CITY ZIP CO.

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