Consumer Registration Form /
Formulario de Registro Consumidores
Every new SummitStone Health Partners consumer must fill out this form. It requests basic information about your name, address, birth date, etc.
Disclosure Statement and Consent to Treat Form /
Declaración de Divulgación y Consentimiento para Tratar Forma
This form provides information about your rights as a client, your agreement to participate in treatment and/or permission for a minor child to be treated.
Financial Agreement/
Acuerdo Financiero
This form provides information about our financial policies and payment expectations.
Release of Information – Loveland/
Divulgación de informacións – Loveland
This form allows us to communicate with anyone (i.e. probation, DHS, your medical providers, family members, etc.) that you would like to have us coordinate treatment/communicate with.
Release of Information – Fort Collins/
Divulgación de informacións – Fort Collins
This form allows us to communicate with anyone (i.e. probation, DHS, your medical providers, family members, etc.) that you would like to have us coordinate treatment/communicate with.
Joint Notices of Privacy Practices /
Aviso conjunto de preácticas de privacidad
This notice tells you how health and drug and alcohol information about you may be used and disclosed and how you can get this information.
Medical Decision Making Form /
Formulario toma de decisiones médicas
This form is required to be completed by the parent, guardian or legal custodian of a minor child.
Request for Access to Protected Health Information /
Petición de Acceso a Información Protegida de Salud
This form is required to be completed by the parent, guardian or legal custodian of a minor child.
ROI Request to Communicate Via Email
This form is required to be completed by the parent, guardian or legal custodian of a minor child.