HOW TO USE THESE FORMS

1. Click form to open
2. Fill information
3. Download completed form to your computer
4. Upload form to your provider’s office using Medical File Share.

    New patients must submit a photo or copy of driver’s license and insurance card, front & back, when submitting a New Patient Request form.

New Patient Request Form

Western Colorado Pediatrics: New Patient Request Form

Western Colorado Pediatrics:
Social Family History Intake

New Insurance Information

Records Release Authorization (ROI)

HIPPA Disclosure Authorization

Parental Consent for Adult Child

Western Colorado Pediatrics: Clinic Overview

Minor Proxy Registration Instructions: Patient Portal

Minor Proxy Release Form:
Patient Portal

Adult Proxy Registration Instructions: Patient Portal

Adult Proxy Release Form: Patient Portal

Separated/Divorced Families Guide- English

Western Colorado Pediatrics: Clinic Overview – Spanish

Separated/Divorced Families Guide- Spanish

Minor Proxy Registration Instructions: Patient Portal – Spanish

Adult Proxy Release Form: Patient Portal – Spanish

Minor Proxy Release Form: Patient Portal – Spanish