Patient Forms

We make our forms available online to help improve your experience at Park City Clinic.

Please click on the links below for additional instructions on the form and how and when to return it.

Release of Information Form

The Release of Information Form is required whenever you request your medical records at Park City Clinic to be transferred to another provider or facility. This form requires your signature. Once completed, please mail or deliver to the office where your medical records are kept.

• Authorization for Release and Disclosure of Protected Health Information
• Authorization for Release and Disclosure of Protected Health Information (Spanish)

Patient Registration

The New Patient Form provides us with the information needed to set up a new patient chart and establish your billing account with Park City Clinic. Please complete this form as accurately as possible. The requested information includes demographics of each patient (name, age, address, date of birth, etc.) responsible party for payment, and any health insurance information that will help us to accurately bill your insurance company. This form is required for all new patients to Park City Clinic.

• New Patient Form
• New Patient Form (Spanish)