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  • Health & Wellness Campus
    • Naming Opportunities
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  • Donate
  • About Us
  • Services
    • Family Medicine Services
    • Behavioral Health Services
    • Crisis Services
    • Virtual & Telehealth Visits
    • Family Dental Services
    • Family Physical Therapy Services
    • Pharmacy
  • Special Programs
    • Nurse Family Partnership
    • Patient Navigation
    • Women, Infants and Children (WIC)
    • Community Engagement Programs
    • Reach Out & Read
    • Residency Programs
    • Youth Respite Services
    • Vocational Training
    • Peer Support
    • Veteran Outreach
    • The Coffee Break Project
    • Community Trainings
  • For Patients
    • Newsletter Sign Up
    • Patient Forms
    • Patient FAQ’s
    • Patient Rights and Responsibilities
    • Insurance and Financial Assistance Program Information
    • Compliance
    • CIIS Registry
    • Transparency in Health Care Prices Act
    • Patient Education
  • Providers
  • Careers
  • Locations
  • Employee Resources
  • Transportation
  • News
  • Contact Us
  • Health & Wellness Campus
    • Naming Opportunities
    • Campus Tours
    • Art Installation
  • Donate
For Appointments Call 833-350-1113
Pay My Bill
Patient Portal
Schedule an Appointment
  • About Us
  • Services
    • Family Medicine Services
    • Behavioral Health Services
    • Crisis Services
    • Virtual & Telehealth Visits
    • Family Dental Services
    • Family Physical Therapy Services
    • Pharmacy
  • Special Programs
    • Nurse Family Partnership
    • Patient Navigation
    • Women, Infants and Children (WIC)
    • Community Engagement Programs
    • Reach Out & Read
    • Residency Programs
    • Youth Respite Services
    • Vocational Training
    • Peer Support
    • Veteran Outreach
    • The Coffee Break Project
    • Community Trainings
  • For Patients
    • Newsletter Sign Up
    • Patient Forms
    • Patient FAQ’s
    • Patient Rights and Responsibilities
    • Insurance and Financial Assistance Program Information
    • Compliance
    • CIIS Registry
    • Transparency in Health Care Prices Act
    • Patient Education
  • Providers
  • Careers
  • Locations
  • Employee Resources
  • Transportation
  • News
  • Contact Us
  • Health & Wellness Campus
    • Naming Opportunities
    • Campus Tours
    • Art Installation
  • Donate
  • About Us
  • Services
    • Family Medicine Services
    • Behavioral Health Services
    • Crisis Services
    • Virtual & Telehealth Visits
    • Family Dental Services
    • Family Physical Therapy Services
    • Pharmacy
  • Special Programs
    • Nurse Family Partnership
    • Patient Navigation
    • Women, Infants and Children (WIC)
    • Community Engagement Programs
    • Reach Out & Read
    • Residency Programs
    • Youth Respite Services
    • Vocational Training
    • Peer Support
    • Veteran Outreach
    • The Coffee Break Project
    • Community Trainings
  • For Patients
    • Newsletter Sign Up
    • Patient Forms
    • Patient FAQ’s
    • Patient Rights and Responsibilities
    • Insurance and Financial Assistance Program Information
    • Compliance
    • CIIS Registry
    • Transparency in Health Care Prices Act
    • Patient Education
  • Providers
  • Careers
  • Locations
  • Employee Resources
  • Transportation
  • News
  • Contact Us
  • Health & Wellness Campus
    • Naming Opportunities
    • Campus Tours
    • Art Installation
  • Donate

Forms for Medical, Dental & Physical Therapy Patients

If you have an in-person visit, please print and fill out all forms and bring them with you to your appointment. All forms can be handed to the front desk during check-in.

English

Patient Information Form
Consent for Treatment
Health History
Mandatory Disclosure Integrated Behavioral Health
Notice of Privacy Practices
Release of Information
Patient Information Brochure
Advance Beneficiary Notice
Authorization for Designated Client Representative
Patient Decision Against Medical Advice

Spanish

Informacion del Paciente
Consentimiento para Tratamiento
Historial de Salud
Servicios Integrado de Salud Conductual
Aviso de Practicas de Privacidad
Autorizacion para Divulgar de Expedientes Medicos Protegidos
Informacion Para el Paciente
Aviso Anticipado de no Cobertura al Beneficiario
Decision del Paciente Contra el Consejo Medico

Additional Forms for Patients Under 18 or Adolescents

Adolescent Visit Consent
Unaccompanied Minor
Partial Parental Delegation Authority
Financially Independent Minor
Consentimiento para una Visita de Tratamiento de un Adolecente
Menor No Acompanado
Delegacion de Autoridad Parcial de los Padres para el Tratamiento
Menor de edad Financieramente Independiente

In 2021 a new Colorado law was passed that allows minors to consent to obtaining certain vaccines. Parental or legal guardian approval is now not required for minors (people under age 18) to obtain the human papillomavirus (HPV), hepatitis A, and hepatitis B vaccines during a healthcare visit that includes the discussion of reproductive health. Click here to learn more. 

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Patient Portal
Pay My Bill
Contact Us
  • About Us
  • Services
    • Family Medicine Services
    • Behavioral Health Services
    • Crisis Services
    • Virtual & Telehealth Visits
    • Family Dental Services
    • Family Physical Therapy Services
    • Pharmacy
  • Special Programs
    • Nurse Family Partnership
    • Patient Navigation
    • Women, Infants and Children (WIC)
    • Community Engagement Programs
    • Reach Out & Read
    • Residency Programs
    • Youth Respite Services
    • Vocational Training
    • Peer Support
    • Veteran Outreach
    • The Coffee Break Project
    • Community Trainings
  • For Patients
    • Newsletter Sign Up
    • Patient Forms
    • Patient FAQ’s
    • Patient Rights and Responsibilities
    • Insurance and Financial Assistance Program Information
    • Compliance
    • CIIS Registry
    • Transparency in Health Care Prices Act
    • Patient Education
  • Providers
  • Careers
  • Locations
  • Employee Resources
  • Transportation
  • News
  • Contact Us
  • Health & Wellness Campus
    • Naming Opportunities
    • Campus Tours
    • Art Installation
  • Donate
  • About Us
  • Services
    • Family Medicine Services
    • Behavioral Health Services
    • Crisis Services
    • Virtual & Telehealth Visits
    • Family Dental Services
    • Family Physical Therapy Services
    • Pharmacy
  • Special Programs
    • Nurse Family Partnership
    • Patient Navigation
    • Women, Infants and Children (WIC)
    • Community Engagement Programs
    • Reach Out & Read
    • Residency Programs
    • Youth Respite Services
    • Vocational Training
    • Peer Support
    • Veteran Outreach
    • The Coffee Break Project
    • Community Trainings
  • For Patients
    • Newsletter Sign Up
    • Patient Forms
    • Patient FAQ’s
    • Patient Rights and Responsibilities
    • Insurance and Financial Assistance Program Information
    • Compliance
    • CIIS Registry
    • Transparency in Health Care Prices Act
    • Patient Education
  • Providers
  • Careers
  • Locations
  • Employee Resources
  • Transportation
  • News
  • Contact Us
  • Health & Wellness Campus
    • Naming Opportunities
    • Campus Tours
    • Art Installation
  • Donate

Main Office: 128 Market Street, Alamosa, CO 81101 | 719-587-1001
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Recognized by the American Heart Association (2025)

Recognized by the American Heart Association: Target BP (2025)

Accredited/Certified by
HRSA Health Center Program Operational Site Visit

HRSA Recognition: Addressing Social Risk Factors (2023)

HRSA Recognition: Advancing HIT for Quality (2023)

HRSA Recognition: Access Enhancer (2023)

HRSA Recognition: Health Disparities Reducer (2023)

AAAHC Accreditation

HRSA Recognition: Patient Centered Medical Home

FTCA Seal 5.3.22