Helpful information for you to know.
At Mountain West Medical Center, we're here to help you heal—and to make certain your experience with us is as safe, restful and restorative as possible. However, before you visit us, there are a few things you might want to know about our campus, checking in and making the most of your hospital stay.
Questions of care.
Did you know that as a patient, you have a specific set of rights? That our hospital accepts most major insurers (but that you should check our list to make sure yours is among them)? That we offer spiritual counseling and other services? Read on to find out more.
Release of Medical Information:
Download the Release of Medical Information form here.
Please fill out all highlighted sections, including:
- Patient’s Name, Date of Birth, Address and Phone Number
- Facility Authorized to Release Information to:
- Records Released to you - write in “SELF"
- Records Released to another Provider or Facility - please fill in the Providers name, address, phone and FAX number.
- Health Information to be disclosed - include all dates of
service, what type of records you want released (labs, x-ray, complete,
etc.), why you need the information (treatment, insurance, personal),
- The Yes/No question is an authorization to release any sensitive
information. Typically this should be marked yes if you require all of
your information to be released.
- Patient’s or Authorized Personal Representative’s Signature – please sign, date and time.
- Leave the Witness Signature line and everything below it blank.
You will also need to include a legible copy of your DRIVER’S
LICENSE or your Official ID so we may verify your signature with your
hospital record.
After downloading and filling out this form, please fax to 858-430-4615, mail to: Mountain West Medical Center, Attn: Health Information Management Department, 2055 N Main St, Tooele UT 84074, or email to
mwmc_roi@quorumhealth.com. If you have question, please call 435-843-3722.