Administrative Forms

• Release of Information Form
• Verification of Insurance Information/Non-Covered Service Waiver
• Registration Form
• No Show Policy Form

• Verificación de Información de Seguro
• El Formulario de Registro

Use this form to:
- Request medical records to be sent to Utah Valley Pediatrics from another physician.
- Send medical records from Utah Valley Pediatrics to another physician (transferring care).
- Authorize the release of protected health information to another individual.

Download Form

Print the form, complete the appropriate sections and either fax it, mail it or bring it in to your physician's office. Fax numbers and addresses are listed on the Offices, Locations page.

To ensure accurate billing and timely payment from your insurance company, Utah Valley Pediatrics has a company- wide policy to verify your child’s insurance information at every visit.

Single Child Form
Multiple Children Form

Form for new patients.

Registration Form

No Show Policy Form

Para garantizar la facturación adecuada y pago oportuno de su compañía de seguros, Utah Valley Pediatrics tiene una política en toda la empresa para verificar información de seguros de su hijo en cada visita.

Formulario Para Un Niño
Formulario Para Varios Niños

El formulario de registro para pacientes nuevos.

El Formulario de Registro