New Patients

Patient Intake Forms

Save time at your visit by filling out your intake form ahead of time. Complete it online and print, or download a PDF version.

Before Your Visit

What to Bring

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Photo ID
A valid government-issued photo ID such as a driver's license or passport.
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Insurance Card
Your current insurance card. Check our insurance page if you're unsure whether we accept your plan.
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Method of Payment
A credit card, debit card, or cash for your co-pay or any out-of-pocket costs.
PDF Downloads

Download & Print

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Printable Version
Download and print this version, then fill it out by hand before your visit. Bring the completed form with you.
⬇ Download Printable PDF
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Writable PDF Version
Download this version to type directly into the PDF on your computer or device. Save and bring a printed copy, or bring it on your device.
⬇ Download Writable PDF
Online Option

Fill Out Online & Print

Prefer to fill out your form in your browser? Complete the form below, then use the Print button at the bottom to print it and bring it to your visit.

Fill out the form, then print and bring it to your visit.
Visit Information
Patient Information
Primary Insurance
Secondary Insurance
Primary Person to Insurance
Financially Responsible Party (if different from patient)
Contacts
Emergency
Contact HIPAA
Contact
Pharmacy
Consents

I give authorization to release any medical information necessary to process this and any future claims, and authorize payment of medical benefits for all physician services or supplies to be made to 20 Mile Urgent Care and Family Medicine.

I hereby acknowledge that I have been given the opportunity to review the privacy practices of 20 Mile Urgent Care and Family Medicine.

Consent for Treatment of Minors: I understand that a minor child (17 and under) must have my consent to be treated at 20 Mile Urgent Care & Family Medicine. I understand that I must be present at each appointment for any child age 14 or younger. I also understand that Colorado Law provides minors to seek care without parental consent for certain issues.

20 Mile Urgent Care & Family Medicine
Financial Policies

We participate with most insurance plans. With several we have a dual contract being both Family Medicine and Urgent Care. It is your responsibility to check with your insurance to verify your plan participation with our clinic. We will help you in any reasonable way to collect from your insurance carrier, HOWEVER THE ULTIMATE OBLIGATION FOR PAYMENT FOR SERVICES RESTS WITH YOU OR YOUR RESPONSIBLE PARTY.

Financial Responsibilities

We require that you provide us with copies of a photo ID and your current insurance card at every visit. If we cannot verify your insurance eligibility with the information you provide, payment in full is expected at the time of your visit. Co-Payments are collected at the time services are rendered. Any outstanding balance from deductibles, co-insurance, etc. are due in full upon receipt of your statement.

Referrals

It is your responsibility to know your insurance requirements. If your insurance requires that you obtain a referral for a visit other than at your primary care provider's office, then it is your responsibility to obtain that referral.

Self-Pay

We offer services for non-insured patients; however, the reception staff is unable to quote prices for these services.

Collection Fees

If we must employ a collection agency to collect on any unpaid balances, you will be responsible for any collection fees, court costs and other reasonable collection expenses.

Returned Check Fees

There will be a charge of $30 for any check that is not honored by your bank. This overdraft could also prevent us from accepting checks from you in the future.

I have read and understand the above financial policies.

Fill out the form, then print and bring it to your visit.