Family/Household Member Patient Registration 
Student/Employee Information
School Affiliation (Please check box below)*
Sex at Birth*
Family/Household Member Information
Sex at Birth*
Family/Household Member Health Insurance Information

I, as a patient of the Health Center at Auraria, do hereby voluntarily consent to medical and/or behavioral health care, encompassing diagnostic procedures and medical treatment by the Health Center staff. I am aware that the practice of medicine/surgery is not an exact science. I acknowledge that no guarantee or assurance has been made to me concerning the results of my treatment. I also understand that per state guidelines my medical records may be destroyed 7 years from my last date of service.

Authorization to release medical information: I authorize the release of medical information to my insurance company, for charges submitted to them for services billable by the Health Center, in order to process or pay my medical claims. I understand that University of Colorado Hospital, the contracting physician agency for medical services at the Health Center, will be provided with patient information. For detailed information on the release of protected health information, refer to the current Notice of Privacy Practices for the Health Center

Authorization to pay benefits to the Health Center at Auraria: Patients using their health insurance for charges  incurred  do hereby assign payment directly to the Health Center at Auraria for billable charges, not to exceed contracted rate for each charge. Ancillary services received at the Health Center, such as lab testing or X-rays, may result in additional charges billed by a third-party. In addition, I understand that I will be responsible for payment to the Health Center at Auraria for any charges not covered by my medical insurance benefits and for any associated denials, co-payments, deductibles or co-insurance.

Payment Policies: Patients that are unable to use health insurance for payment are expected to pay at the time of service, unless prior arrangements have been made. A $20.00 charge will be assessed for all returned checks, disputed credit card charges and returned medications. If you have a scheduled appointment (for any service) and fail to notify us of any change (rescheduling) or cancellation 24 hours in advance, you can be assessed a fee due to our inability to utilize the time slot for other patients in need of our services. A service fee will be added on balances that are 60 days overdue and assessed every semester thereafter. Balance limits cannot exceed $400 with minimum monthly payments of no less than $25.

I understand and agree to the policies/terms outlined in this document and my signature signifies my agreement. I further understand and agree that my signature will remain valid for as long as (and whenever) I am a patient at the Health Center at Auraria. It is my responsibility to inform the Health Center of any changes to my personal information. If changes do occur (other than a name change), and my file is updated per information I provide, my original signature and agreement will remain in force and valid.

By typing my full name below, I am electronically signing this document and acknowledge that this is a legal equivalent to my handwritten signature. By signing, I acknowledge that I have provided accurate information and agree to the terms and conditions of this document.