Patient Registration CVCC

Patient Information:





Mailing address:

If minor, Parent information



Person to contact in case of an emergency if unable to reach the parent/legal guardian listed above.

Primary Insurance:

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Policy Holder name:

Secondary Insurance:

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Policy Holder name:

Other information:


I authorize Castle Valley Children’s Clinic to disclose all or any part of the patient’s medical record and/or clinic charges (including information regarding alcohol or drug abuse, psychiatric illness or communicable disease related information including HIV) to any person or corporation (i) which is or may be liable or under contract to Castle Valley Children’s Clinic for reimbursement, subrogation and/or direct recovery and coordination of benefits for this and all future claims including but not limited to hospital/medical service companies, workers’ compensation carriers, welfare funds, governmental agencies and (ii) any health care provider for continued patient care.
Except, as above, Castle Valley Children’s Clinic will require the patients, or in the case of a minor child, a natural parent or legal guardian’s, written consent to release information about the patient.
I also agree that in all instances, the original medical records (including x-rays and laboratory specimens) remain the property Castle Valley Children’s Clinic.


In the event the patient, his/her authorized representative or the guarantor signing below, is entitled to benefits of any type arising out of any policy of insurance insuring the patient or any other party liable to the patient, those benefits are hereby assigned to Castle Valley Children’s Clinic for application against the patient’s bill. Such payment shall discharge that insurance company of any obligation under the policy to the extent that payment has been made correctly according to the terms of the policy. The undersigned shall remain responsible for any and all charges not paid by the insurance company and/or not covered by this assignment.
I assign the benefits payable for services to the organization furnishing the services or authorize such organization to submit a claim for Payment. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, are hereby assigned to Castle Valley Children’s Clinic.


I agree that in return for the services provided to the patient by Castle Valley Children’s Clinic, or other health care providers, I will pay the account of the patient prior to discharge or make financial arrangements satisfactory to Castle Valley Children’s Clinic or any other providers for payment. I understand and I agree (regardless of my insurance status) to assume full financial responsibility for all charges incurred, including collection fees, interest, Attorney fees and court costs.


By signing below, I state that I am the natural parent or legal guardian having legal custody.
I give permission for Castle Valley Children’s Clinic Inc. to perform or administer examination, anesthetic, medical or surgical diagnosis and/or treatment under the general or special supervision and on the advice of any physician, nurse practitioner or surgeon licensed in the State of Colorado, when the need for such treatment is clear, and when efforts to contact me are unsuccessful.
This authorization shall remain effective for one (1) year from the date of signature unless sooner revoked in writing and delivered to Castle Valley Children’s Clinic.


PATIENT ACKNOWLEDGMENT Our Notice of Privacy Practices provides information about the privacy rights of our patients; and how we may use and disclose protected health information (PHI) about our patients.
Federal regulation requires that we give our patients or their authorized representative the opportunity to review our Notice before signing this acknowledgment. A copy of our Privacy Policy is available at the front desk.
By signing this form you knowledge only that we have provided you with immediate access to our Notice of Privacy Practices.

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