Table of Contents

Release of Information Form (Authorization to Use and Disclose Protected Health Information):

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.

Print the form, complete the appropriate sections and either fax it, mail it or bring it to your physician's office.

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Verification of Insurance Information/Non-Covered Service Waiver

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.

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Registration Form

Form for new patients.

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Verificación de Información de Seguro / Renuncia al Servicio No-Cubiertos

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.

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El Formulario de Registro

El formulario de registro para pacientes nuevos.

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