Forms

New Patient Registration Packet

If you are a new patient of ours, we welcome you to fill out the necessary paperwork ahead of your appointment. (This really speeds up your check-in at the time of your appointment and can help you see your doctor even faster!)

*Note* Patients Transferring Care from Saltzer Medical Group

Your medical record can be transferred to Full Circle Health in the following ways:

Call: 1-855-821-0591 or,

Send a written request to:
Centralized Release of Information
500 Eldorado Blvd. Building 4
Broomfield, CO 80021

Or,

Email: SaltzerARC@imail.org

Please bring your medical record with you to your first appointment with us. We appreciate your assistance with the transition as we welcome you to Full Circle Health.

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Pre-visit Patient Checklist

Need a worksheet to track your medications or make notes for your doctor?

Download this handy patient checklist and bring it with you before seeing your doctor at your next appointment!
(English Worksheet)
(Spanish Worksheet)

Or, fill out an electronic version to send to your personal email account to keep track of, try it HERE.

Parental Consent to Treat Minors

Parental consent is a process that ensures you, as a parent, understand and agree to the medical treatment or medication your child may receive. According to Idaho Senate Bill 1329, this process involves providing you with information about the proposed treatment, including its benefits, risks, and alternatives. The exceptions however are court orders, emergency situations, and emancipations.

Parental Consent for Minors is required on or after July 1, 2024. If you would prefer to select specific treatment options with your child’s primary care provider, please make an appointment with us. Learn More About Parental Consent

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Scan your completed form and email to: Registration@fullcircleidaho.org
Or, drop off your completed form to any Full Circle Health clinic location during regular business hours.

Sliding Fee Application

We are so happy to offer a sliding fee discount program to eligible individuals based on the patient’s ability to pay.  Ability to pay is determined by the household size and annual income relative to a discount schedule based on federal poverty income guidelines.

If you would like to apply, please fill out the following application:

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2025 Sliding Fee Rate Card – English
2025 Sliding Fee Rate Card – Spanish

3rd Party Release of Health Information

If you would like a 3rd party to be given the permission/ability to discuss your healthcare with our staff, please fill out the following form. (Note: If you are a new patient, this form is already included in your registration packet.)

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Authorization to Release Health Information

Unlike the 3rd party release form, the Authorization to Release Health Information form is a form that releases health information from your medical record; whether that be to someone in your family or another medical institution. (Note: if you are a new patient, this is not included in your patient registration packet.)

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Revocation of HIPAA Authorization For Use, Disclosure, and Access to Protected Health Information (PHI)

You have the right to revoke or take away permission to disclose or share your health information. Completing this form, you are revoking permission for Full Circle Health to disclose or share your health information with named individuals and/or entities.

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