FASAHA & SIYAASADA | Salaan
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FOOMKA & NIDAAMKA

WHAT TO BRING TO YOUR FIRST APPOINTMENT

To help us serve you as quickly as possible, please complete and bring the appropriate forms to your first visit.
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Required Forms

  1. PATIENT REGISTRATION FORM - English | Español

    • To add any minors you are also registering - 
      MINOR PATIENT REGISTRATION FORM -       English | Español

    • If you are only registering minors that you are the parent/guardian of and not yourself - 
      MINORS ONLY PATIENT REGISTRATION FORM –       English | Español

  2. HEALTH INFORMATION RELEASE FORM - English | Español

  3. BEHAVIORAL HEALTH CONSENT FORM - English | Español

  4. All items listed in the ENROLLMENT VISIT CHECKLIST - View Checklist
     

Proof of Income

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

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Connect for Health Colorado

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 the EMPLOYEE COVERAGE TOOL - View the tool

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Medicare Annual Wellness Visit

IF you are scheduled for a Medicare Annual Wellness Visit, please print out this form, complete it, and bring to your visit:

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NOTICE OF REQUIRED INFORMATION

As a Federally Qualified Health Center (FQHC), we are required to collect certain information annually as part of your patient registration, including:​

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Please note, that to receive care at our clinic and remain an active patient, you must complete the income and household size annually.

DAAWEYNTA AAD 

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 A NON-PARENT/GUARDIAN - English | Español

  • AUTHORIZATION FOR TREATMENT OF A MINOR WITHOUT A PARENT/GUARDIAN PRESENT - English | Español

SALUD FOOMKA GUUD & XEERARKA 

CONSENT FOR TREATMENT - Consent for medical, behavioral health, and dental treatment - English | Español

IMMUNIZATION INFORMATION OPT OUT - To remove your/your child's immunization information - English

MISSED OR LATE APPOINTMENT POLICY - Describes appointment arrival, cancellations, and missed visit policies - English | Español

NOTICE OF PATIENT’S RIGHT TO LANGUAGE ASSISTANCE AND NON-DISCRIMINATION - Language Assistance + Non-Discrimination Policy

NOTICE OF REQUIRED INFORMATION - Describes annual requirement for certain registration information - English + Español​

PATIENT FINANCIAL RIGHTS AND RESPONSIBILITIES - Explains patient payment expectations, and financial assistance - English | Español

PATIENT RIGHTS & RESPONSIBILITIES - Describes the rights and responsibilities of a Salud patient - English | Español

PRIVACY POLICY - Describes how Salud protects your health information - English | Español

SALUD IS YOUR MEDICAL HOME - Describes how Salud serves as your Medical Home - English | Español

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