Patient Information

1. GENERAL INFORMATION

Sex at Birth *
Gender Identity (please check box below)
Sexual Orientation (please check box below)
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Marital Status (please check box below)
Racial Group (please check box below)
Preferred Contact Number
School Status (Please check box below) *
School Affiliation (Please check box below) *

2. EMERGENCY CONTACT INFORMATION

If you are under 18, you must informat the front desk. Parent/guardian information required.

3.HEALTH INSURANCE INFORMATION

CATEGORY 1: I am currently enrolled and particapte in medicaid or medicare (Please check boxes below)
Medicaid
Medicare
CATEGORY 2: I participate in one of the University Sponsored Student Health Insurance Plans (Please check boxes below)
MSU Denver Student Insurance *
CU Denver International *
CU Denver Domestic U.S. Plan *
CATEGORY 3: I am insured with outside health insurance (Please provide details below)
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CATEGORY 4: I do not have any health insurance

CATEGORY 5: Read Health Center terms and conditions.

I, 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.

Internal confidentiality of medical records: Routine processing of patients requires Health Center staff to access patient records, which include general medical, psychiatric and/or specialist physician notes. All medical records are kept confidential and all Health Center personnel must sign a “confidentiality agreement” as a condition of their employment. Inter-agency consultation may occur with the applicable campus Counseling Center(s) and/or CARE Teams to coordinate care when appropriate.

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.
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