Medical Patient Forms
Medical Patient Registration Form
Your time is valuable and sitting in a waiting room filling out papers can be a hassle. As a patient, Grand Peaks requires basic information. Please complete the New Patient Registration form, sign, and date. The form will guide you to any required fields you may have missed, and also prompts you for your Photo ID & Insurance Card (if any). Once completed they are securely emailed to the clinic, saving you time during the check in process!
For New Patient Registration:
To apply for our Sliding Fee Discount, which is based on your household size and income, please complete the Sliding Fee Discount Application. The information on this application also has to be verifiable with proof of income, and must be submitted to our facility within 3 days of your appointment, otherwise full fee will be charged. This application is available in our New Patient Registration Packet.
Proof of income options
Patients who wish to apply for sliding fee discounts are only required to provide one of the following:
- 2 most recent pay-stubs for all members of the household who are working
- Previous year’s tax documents
- Social Security or Disability income statements
- If you have no verifiable income, a letter from someone close to you (may not be a family member) that can verify your income and financial situation. This letter must be signed and dated, and a phone number to reach this person is required.
- If you have recently started a new job, the employer may either write a letter or you may have them complete our Income Verification form. This form must be signed and dated.
HIPAA Notice and Form
Your Privacy is very important to us! If you ever have a concern or question, please contact our facility ASAP. The HIPAA/Privacy Notice is a document for your information.