Skip to content
GRAND JUNCTION: 970-644-5999 | MONTROSE: 970-240-8199 | GLENWOOD SPRINGS: 970-404-8700
Facebook
Trailhead Clinics Logo Trailhead Clinics Logo Trailhead Clinics Logo
  • About Us
    • Our Team
    • Careers
  • Our Locations
    • Grand Junction
    • Montrose
    • Glenwood Springs
  • Our Services
    • Direct Primary Care
    • Aesthetics
  • Patient Resources
    • Health History Form
    • Español
    • Blog
    • Wellness Partnerships
  • Employer Plans
  • Contact Us
  • Join Here
  • About Us
    • Our Team
    • Careers
  • Our Locations
    • Grand Junction
    • Montrose
    • Glenwood Springs
  • Our Services
    • Direct Primary Care
    • Aesthetics
  • Patient Resources
    • Health History Form
    • Español
    • Blog
    • Wellness Partnerships
  • Employer Plans
  • Contact Us
  • Join Here
  • Home
  • About Us
    • Locations
      • Grand Junction, CO
      • Montrose, CO
      • Glenwood Springs, CO
    • Career Opportunities for Healthcare Professionals
  • Why Join?
    • Membership Services
    • Corporate Plans
    • Partnerships
  • Join Us
    • Grand Junction, CO
      • Individual & Family Plans
      • Employer & Group Plans
    • Montrose, CO
      • Individual & Family Plans
      • Employer & Group Plans
    • Glenwood Springs, CO
      • Individual Family Plans
      • Employee Healthcare in Glenwood Springs
  • Aesthetics
  • Forms
    • Complete Adult Health History
    • Español
      • Registrarse en Trailhead Clinics Glenwood Springs
      • Forma de Historial Medico
      • Autorizacion para Compartimiento de Registros Medicos
      • Forma de liberación de HIPAA
  • Blog
  • Contact Us

Forma de liberación de HIPAA

Forma de liberación de HIPAAMarche Boyer2024-10-17T14:24:27-06:00


MM slash DD slash YYYY

Permiso para Comunicar Información

Autorizo el compartimiento de información incluyendo el diagnóstico, registros; exámenes y reclamos de información. Con las siguientes personas:
Esta información puede ser compartida con:
Esta información permanecerá vigente hasta que yo la rescinda por escrito.
Mensajes
Por favor llame a:
Si no puede comunicarse conmigo:

Grand Junction

  • 235 N. 7th Street,
    Grand Junction, CO 81501
  • 970-644-5999
  • info@trailheadclinics.com
Mon - Fri: 8am-5pm
Sat-Sun: Closed

Montrose

  • 401 South Park Avenue,
    Montrose, CO 81401
  • 970-240-8199
  • info.montrose@trailheadclinics.com
Mon - Fri: 8am-5pm
Sat-Sun: Closed

Glenwood

  • 1607 Grand Ave. Unit 22
    Glenwood, CO 81601
  • 970-404-8700
  • info.glenwood@trailheadclinics.com
Mon - Fri: 8am-5pm
Sat-Sun: Closed

Visit Us:

All Rights Reserved | Trailhead Clinics
Facebook
Page load link
Go to Top