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MOAB REGIONAL HOSPITAL 450 W WILLIAMS WAY, MOAB UT 84532 PHONE: 4357193500 FAX 4357193719 AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) Patient Name: DOB: Address: Date: Phone:
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Collect all necessary personal and medical information of the patient.
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Moab Regional Hospital is a healthcare facility located in Moab, Utah.
Moab Regional Hospital must be filed by healthcare providers and facilities in the Moab area.
To fill out Moab Regional Hospital, providers need to submit patient and treatment information.
The purpose of Moab Regional Hospital is to track and report healthcare services provided in the region.
Information such as patient demographics, diagnoses, treatments, and outcomes must be reported on Moab Regional Hospital.
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