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Ute Pass Regional Health Service District

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Request Forms

The forms on this page are available as downloads for printing. Clicking each link will open the document in a new window. You may print directly from the page or save the document to your computer for future use. Be advised, these documents are updated occasionally so be sure you always have the latest version before printing.

  • Consent for Treatment/Transport, Billing and Privacy
  • Physician Certification Statement (PDF)
  • Release of Care
  • Third-Rider Liability Waiver

Did you know…

The Medic 16 ambulance was literally built for safety. Members of our organization worked hand and hand with leaders in ambulance design to develop a truly state of the art safety concept. This design is now being duplicated all over the industry. It was built at a lower cost than our other ambulances and has a cutting edge V10 gas engine with a much lower cost of ownership.

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