Patient Information Spanish

Call (303) 772-3300 or TEXT (303) 622-0630 to schedule an appointment.

Please complete all 4 new patient forms. You will automatically be directed to the next form upon submission of the current form. This is form 1 of 4.

ECCNC takes the privacy and security of your personal information very seriously. All data submitted through the form on this page is transmitted and stored using HIPAA compliant encryption technology. If you don’t feel comfortable providing information in a specific box then please write the following in the box: “Please ask”.
Patient Information
Name*
First Last
Gender
Martial Status
Birth Date
Month
Day
Year
Age
Social Security Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact
Emergency Contact Phone
Phone
Home
Phone
Work
Phone
Cell
How did you hear of us?
Email
Employer
Occupation
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pharmacy
Pharmacy Phone
Primary Care Physician
Referring Physician
Medical Insurance Name & Address
Policyholder Relationship
Copay Policy ID Group ID
Guarantor (Person to be billed, if different than patient)
Name
First Middle Last
Gender
Martial Status
Birth Date
Month
Day
Year
Social Security Number
Address
Street Address Address Line 2 City State ZIP Code
Phone
Home
Phone
Work
Phone
Cell
Employer Name
Occupation
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
HIPAA Approved Contacts
Name
First Middle Last
Relationship
Phone
Home
Phone
Work
Phone
Cell
I would like to add another HIPAA contact
Name
First Middle Last
Relationship
Phone
Home
Phone
Work
Phone
Cell
CMS / ONC Electronic Health Record requirement.
Ethnicity
Race
Language
Patient's or Authorized Person's Signature
I the undersigned give my authorization to treat and assign directly to Eye Care Center of No. Co. all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all approved and covered charges whether or not paid by insurance. I acknowledge receipt of the Practice's Notice of Privacy Practices. I authorize the Practice to use and disclose my health information for purposes of treatment, obtaining payment of benefits and for services rendered. I consent to be contacted by mail, email or cell phone regarding any matter related to my Eye Care Center accounts by the provider, creditor, its successors, 3rd party collection agencies or assigns. This consent includes contact information that I may provide and includes phone calls that employs auto-dialer technology and prerecorded messages. To revoke consent to call my cell phone, I agree to provide notice by mail to Eye Care Center of No. Co. 1400 Dry Creek Dr. Longmont, Co 80503
Signature Date
Month
Day
Year

Patient Information Spanish

Patient Information

Guarantor (Person to be billed, if different than patient)

HIPAA Approved Contacts

CMS / ONC Electronic Health Record requirement.

Patient's or Authorized Person's Signature

BOULDER

LAFAYETTE

LONGMONT

GREELEY

Medical Insurance	Name & Address

Policyholder	Relationship

Copay	Policy ID	Group ID

Patient Information Spanish

Patient Information

Guarantor (Person to be billed, if different than patient)

HIPAA Approved Contacts

CMS / ONC Electronic Health Record requirement.

Patient's or Authorized Person's Signature

Are you sure?