Patient Forms & Notices

You can fill out your forms online or if you prefer, you may print and fill them out at home. If you’re unable to file online or print, please arrive 20 minutes before your appointment to ensure enough time to fill out the forms. Don’t hesitate to contact us with any questions!

Authorization Forms

Authorization for Release of Protected Health Information - ENG

Autorización para solicitar información médica protegida - ESP

Minor Consent Guide

Minor Consent Information

Discount Forms

Sliding Fee Discounts

SFD Room and Board Letter - ENG

SFD Room and Board Letter - ESP

SFD Employer Letter - ENG

SFD Employer Letter - ESP

SFD CICP Guide

SFD Profit and Loss

Women’s Wellness Connection

WWC Client Profile Tool - ENG

WWC Client Profile Tool - ESP

WWC Consent Form - ENG

WWC Consent Form - ESP

Vaccine Policy

English

Spanish

Notice of HIPAA Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review carefully.

English

Spanish

Colorado Immunization Information System

• Tepeyac Community Health Center participates in the Colorado Immunization Information System (CIIS).

• CIIS is a confidential, population-based, computerized system that collects and consolidates vaccination data for Coloradans of all ages from a variety of sources. 

• CIIS helps healthcare providers, schools, childcare centers, universities, and individuals keep track of the shots that they and/or their children have received.

• CIIS is a program within the Colorado Immunization Section at the Colorado Department of Public Health and Environment (CDPHE). CIIS is a lifelong immunization record tracking system under the Colorado Immunization Registry Act of 2007.

• Learn more information on the CIIS program website.

• To exclude yours or your child’s information from CIIS, visit the CIIS opt-out procedures web page to opt out of the registry. You will also find information on how to rescind a prior opt out.

Contexture/CORHIO Health Information Exchange (HIE)

• Tepeyac Community Health Center participates in Contexture (formally known as CORHIO), a health information exchange (HIE), to improve the quality of your health and healthcare experience.

• The HIE provides us with a way to share patients’ clinical information electronically securely and efficiently with other physicians and health providers that participate in the HIE network. Using HIE helps your health care providers more effectively share information and provide you with better care. The HIE also enables emergency medical personnel and other providers who are treating you to have immediate access to medical data that may be critical for your care. Having your health information available to your health care providers through the HIE can also reduce your costs by eliminating unnecessary duplication of tests and procedures. You may choose to opt-out of participation in the HIE, or opt back in, at any time. If you choose to opt-out, ask a staff member for an Opt-Out Form.

• You can also “opt out” directly with Contexture:

• Print this Contexture Health Information Exchange Opt-Out Form: English PDF or Spanish PDF

• Fill out the form completely and have a notary public verify your information and sign it. This is required for your protection and to verify identity.

• If you are acting as a guardian or authorized representative for a patient over the age of 18, we require documentation of this relationship to be submitted Contexture along with the notarized form. If you have questions about this documentation, please contact Contexture.

• Mail the original form to:

Attn: Service Desk – Colorado HIE Request

4500 Cherry Creek South Drive, Suite 820

Denver, CO 80246

• Note: Contexture’s HIE in Colorado was formerly named CORHIO. While some forms may reflect the previous name due to legal requirements, they are still valid and applicable to all providers participating in the Contexture HIE.