Member Forms

Below are forms for you to complete before your first visit. You can print and complete these at home before you visit the clinic. If you’d prefer not to print them at home, we’ll have copies ready for you to review and sign before your visit.

  • Mint Health Clinics Lone Tree Member Agreement

    This form contains the details of your membership. Only the primary member in a family needs to sign, but all members in the family should be aware of its content.

  • Electronic Communications Agreement

    This form contains the details about how we can communicate with you via text, phone, or video chat. Each member who wants to communicate with our clinic electronically must sign this form.

  • Member Enrollment Form

    This form asks for information such as your name, address, preferred pharmacy (if applicable), emergency contact(s), and billing information.

  • Health History Questionnaire. Your answers to the questions in this form will help us understand your or your child’s medical history, and any concerns you’d like to discuss with your physician.

  • HIPAA Consent

    This form notifies you of your rights to privacy regarding your Protected Health Information (PHI).

  • Notice of Privacy Policies

    This form describes how medical information about you may be used and disclosed and how you can get access to this information.

  • Member Rights and Responsibilities

    This form describes your rights and responsibilities, terms of agreement, and the financial policy of Mint Health Clinics Lone Tree.

  • Release of Medical Record Authorization

    This form specifies your authorization to release and disclose information from your previous physician/facility to Mint Health Clinics Lone Tree. You need to complete this form only at the time you want to disclose previous medical records to us.

  • Medicare Beneficiary Private Contract Agreement

    Due to federal regulations, the physicians at Mint Health Clinics Lone Tree have elected “opt out” status regarding Medicare participation. This means that Medicare cannot be billed for any services you receive from our clinic. If you are eligible for Medicare, you will need to sign this form stating that you agree not to bill Medicare for any services you receive from our clinic.