Miners Hospital

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Application

Established to Serve Utah's Disabled Miners

hand holding papers

The Miners Hospital application must be completed and received before the first appointment can be scheduled. You may download it and fill it out or fill it out online and print it.

Send it back by mail or fax to the Miners Hospital and Clinic. (Address and fax number are found at the bottom of this page.)

You will be asked to provide insurance information and a health history will be completed at your first clinic appointment.

Application Form