FORMS & POLICIES

TO BRING TO YOUR FIRST APPOINTMENT

1. PATIENT REGISTRATION FORM- ADULT or CHILD

2. HEALTH INFORMATION RELEASE FORM

3. ITEMS LISTED IN THE ENROLLMENT VISIT CHECKLIST

IF you are unable to bring pay-stubs as proof of income, please fill out the:

EMPLOYEE INCOME VERIFICATION FORM (your employer must fill out) 

OR

SELF-EMPLOYMENT LEDGER (if you are self employed)

If you are interested in a health insurance plan through Connect for Health Colorado and you (or your spouse) are offered employer health insurance, please fill out this EMPLOYEE COVERAGE TOOL

TREATMENT OF A MINOR 

All children under the age of 18 must be accompanied by a parent or a legal guardian when visiting Salud for the first time and once per year thereafter.

We understand that parents or legal guardians may not always be available to bring their children in and may wish to authorize a child to attend a visit alone or with another adult.  Salud allows children age 13 and older to attend visits alone.  The parent or legal guardian may authorize this in advance of the visit by completing the authorization forms below.

AUTHORIZATION FOR A MINOR TO BE ACCOMPANIED BY SOMEONE OTHER THAN A PARENT/GUARDIAN

AUTHORIZATION FOR TREATMENT OF A MINOR WITHOUT A PARENT/GUARDIAN PRESENT

SALUD GENERAL FORMS & POLICIES 

PRIVACY POLICY- describes how Salud protects your health information

CONSENT FOR TREATMENT- information about the late & missed appointment policy and the financial policy

IMPORTANT INFORMATION- general Salud information

PATIENT RIGHTS & RESPONSIBILITIES- describes the rights and responsibilities of a Salud patient

IMMUNIZATION INFORMATION OPT OUT- to remove your/your child's immunization information from the

  Colorado Immunization Information System

Administration:

203 S. Rollie Avenue

Fort Lupton, CO 80621

(303) 892-6401

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