Patient Demographic Form

  • Contact in case of emergency
  • Insurance Information:

    Primary Carrier:
  • Secondary Carrier:

  • Work Compensation or Auto Accident Information (If Applicable):

  • Assignment of Benefits

    I hereby assign all medical and /or surgical benefits associated with this office, to include major medical benefits to which I am entitled, including Medicare, private insurance, and any other health plan to Colorado Clinic. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby agree to pay any and all charges that exceed or that are not covered by insurance. I hereby authorize said assignee to release all information to secure payment. To insure continuity of care, I hereby authorize the release of all medical records to my primary and referring physicians. I hereby release copies of this information sheet to any hospital I may be admitted to. I also authorize Medicare, private insurance, and any other health plan to furnish said assignee any information regarding payment of my claim.