How To Get Started

New patient
enrollment

We are honored to serve the American Indian and Alaska Native community in Salt Lake City and the surrounding areas. Don’t hesitate to call us at (801) 486-4877 if you have any questions or concerns.

Fill out patient form

You can fill out the New Patient Registration Form online below or fill out an application at any of our locations.

Gather your Documents

In order to be eligible for our programs and services applicants must bring the following:

Certificate of Indian Blood (CIB) or Tribal I.D. (Identification card) A CIB must include the degree of Indian Blood (ex: 1/2, 1/4, etc.)
Social Security Card (or letter from Social Security Administration indicating you have ordered a new or duplicate card)
Current Driver’s License or Photo ID (if registering your child, please bring parent[s] photo ID)
Proof of residency (rental/lease agreement, mortgage, or official mail)
Verification of Income (if applicable) Two pay stubs including SSI or Unemployment
Proof of Medical Insurance Insurance card (if applicable)

All documentation is required at the time of registration. Please allow 24-48 hours for processing the online registration forms.

Schedule Your Intake

Once your paperwork is ready, call us at (801) 486-4877 or visit us in person at 120 W 1300 S SLC, UT 84115. Our registration specialists will help you schedule your first “New Patient Intake” appointment to meet your care team.

Registration form

Please allow 24-48 hours for processing

A Note on Privacy:
Your health information is sacred. UICSL strictly follows all HIPAA regulations to ensure your personal and medical data remains confidential and secure.

I.
Patient Name*
First Middle Last Suffix
Alias or Preferred Name
Internet Access*
- Yes
- No
Where do you access the Internet?
How did you find out about the Urban Indian Center of Salt Lake?*
- Internet
- Family
- Friend
- Advertisement
- Other
What type of UICSL services are you interested in?*
Address*
Street Address City State ZIP Code
Home Phone*
Cell Phone
Date of Birth*
MM slash DD slash YYYY
Sex*
- Male
- Female
- Uknown
Birth Sex*
- Male
- Female
- Unknown
Sexual Orientation*
If other please describe*
Gender Identity(select all that apply)*
- Male
- Female
- Female-to-Male (FTM)/Transgender Male/ Trans Man
- Male-to-Female (MTF)/Transgender Female/Trans Woman
- Genderqueer, neither exclusively male nor female
- Choose not to disclose
- Other – Additional gender category or other, please specify
- Transgender
If other please describe*
Race*
Ethnicity*
Language*
Who is your Primary Care Provider and location?
What is your preferred Pharmacy?
Pharmacy Address?
Street Address City State / Province / Region ZIP / Postal Code
Date you moved to the Salt Lake Area*
MM slash DD slash YYYY
Social Security Number*
Please upload all of the following documentation for Registration: Certificate of Indian Blood or Tribal ID, photo ID, copy of Social Security card, copy of insurance card (if insured - front + back copy) and Proof of Address (lease/bill). Please call Registration office if you have a question on these documents at 801-486-4877
Drop files here or

Max. file size: 2 MB.
Please call Registration office if you have a question on these documents at 801-486-4877
Marital Status
- Single
- Married
- Partner
- Separated
- Divorced
- Widowed
- Unknown
- Legally Separated
II.
Indian Total Blood Quantum - Include all tribes the registering client identifies with.*
- 4/4
- 1/2
- 1/4
- 1/8
- 1/16
Enrolled or Descendancy Tribe*
Tribal Enrollment Number - Found on tribal enrollment document*
Tribe Quantum of enrolled tribe
- 4/4
- 1/2
- 1/4
- 1/8
- 1/16
Other Tribes/Races
If Registering Client is not enrolled with a Tribe, is the Registering Client a Descendant of an Enrolled Tribal Member*
- Yes, a Parent is an Enrolled Tribal Member
- Yes, a Grandparent is an Enrolled Tribal Member
- No, Client has own Tribal ID or Certificate of Indian Blood
If you're Registering via descendancy, please provide your parent or grandparent's CIB/Tribal ID and Birth Certificate(s) that connects the Registering Client to the parent or the grandparent.
Please Upload the Following: Birth Certificate(s)
Drop files here or

Max. file size: 2 MB.
If Registering Client is an Enrolled Tribal Member, this does not apply.
Birth Certificate uploaded is of:
- Parent
- Grandparent
Parent Contact information for Registering Clients ages less than 18 years old:
Father's Name
First Last
Email
Phone
Mother's Name
First Last
Phone
Email
Household
# of members of household
Total Gross Household Income (per month/year):
Household Members (optional)
Name DOB Relationship
Employed
- Yes, part-time
- Yes, full-time
- Yes, seasonal
- No
- Retired
Where?
Spouse, Where Are You Employed?
Veteran
- Yes
- No
Military
- Yes
- No
Service Branch:
Service Entry Date:
MM slash DD slash YYYY
Service Separation Date:
MM slash DD slash YYYY
Vietnam Service Indicated:
Is Service Connected
- Yes
- No
Claim #:
Valid VA Card:
Date VA Card Copy Obtained:
MM slash DD slash YYYY
Upload Copy of VA Card:
Max. file size: 2 MB.
Description of VA Disability:
Homeless
Homeless Type:
City State Zip
Emergency Contact Information
Primary Contact Name
First Last
Primary Contact Relationship
Primary Contact Phone
Secondary Contact Name
First Last
Secondary Contact Relationship
Secondary Contact Phone
Insurance Information
Do you have health insurance coverage? This includes any Private Medical Insurance, Medicare, and Medicaid. If yes please upload a copy of your insurance card with your other documents above.
- Yes
- No
Insurance #1 Name
Policy or Member Number
Name of Insured Person
First Last
Relationship
Insurance #2 Name
Policy or Member Number
Name of Insured Person
First Last
Relationship
Do you have Dental Insurance?*
- Yes
- No
Signature
First Name*
Last Name*
Email*
Date
MM slash DD slash YYYY

How To Get Started

New patient
enrollment

Fill out patient form

Gather your Documents

Schedule Your Intake

Registration form

Please allow 24-48 hours for processing

A Note on Privacy:
Your health information is sacred. UICSL strictly follows all HIPAA regulations to ensure your personal and medical data remains confidential and secure.

I.

II.

Parent Contact information for Registering Clients ages less than 18 years old:

Household

Emergency Contact Information

Insurance Information

Signature

Get In Touch

Complaint Hotline

Hours

Locations

Social

Name	DOB	Relationship

How To Get Started

New patient enrollment

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Registration form

Please allow 24-48 hours for processing

A Note on Privacy:Your health information is sacred. UICSL strictly follows all HIPAA regulations to ensure your personal and medical data remains confidential and secure.

I.

II.

Parent Contact information for Registering Clients ages less than 18 years old:

Household

Emergency Contact Information

Insurance Information

Signature

New patient
enrollment

Fill out patient form

Gather your Documents

Schedule Your Intake

A Note on Privacy:
Your health information is sacred. UICSL strictly follows all HIPAA regulations to ensure your personal and medical data remains confidential and secure.