New and Current Patients

Authorization for Use and Disclosure of Medical Records

Authorization for Use and Disclosure of Behavioral Health Records

Request for Access Form

Notice of Privacy Practices

Patient Rights and Responsibilities

Elevated Care Card Application

Self-Employment Worksheet

Current Sliding Scale Fee Codes

Medicaid Application

Self-Declaration of Income

Autorización para Uso y Divulgación de Historial Médico

Autorización para el uso y divulgación de registros de salud mental

Notificación de Practicas de Privacidad

Derechos y Responsabilidades del Paciente

Aplicación de Tarjeta de Descuentos

Aplicación y preguntas frecuentes sobre Medicaid

Hoja de cálculo de trabajador independiente

Auto – Declaración de Ingresos

Elevated Community Health fees are accrued based on the care you receive. The staff at Elevated Community Health will do the best they can to provide you with a cost estimate. You are required to pay the entire bill at the end of each visit. If needed, you will be offered a payment plan.

If you are uninsured or unsure whether you can afford the cost of care, please refer to our Sliding Fee Scale program below.

How to Apply for an ECH Care Card (Sliding Fee Scale Program)

If you are uninsured or concerned about covering the cost of care, you may qualify for discounted services through our ECH Care Card (Sliding Fee Scale) program. To be eligible, you must complete a short application and go through a formal screening process. We recommend completing this process before you need services, as it takes time to review and process your information.

Steps to Apply:

1. Call us at 970-668-4040 and let the staff know you’re interested in applying for the Care Card.
2. Complete the application forms:

• Care Card Application – English
• Care Card Application – Spanish

3. Submit your completed application and required documents by dropping them off or emailing them to our office. Our Eligibility Coordinator will review your information. If you qualify, you’ll be placed on our Sliding Fee Scale and issued an ECH Care Card.

Payment Information:

• Your co-pay (based on your Care Card level) is due at check-in for each appointment.
• Any additional fees not covered by the Care Card are due at the end of your visit.
• If needed, we’re happy to work with you on a payment plan.

Prefer to Meet In Person?

You can schedule a meeting with our Eligibility Coordinator by calling 970-668-4040. Please arrive 15 minutes early and bring all completed forms and supporting documentation.
Urgent Needs:

If you are very ill and have not yet completed the Care Card process, please inform our front desk. We’ll do everything we can to ensure you receive the care you need.

We are in-network with many carriers. However, you should also check with your insurance to confirm that we are an in-network provider.

We submit your in-network claims to your insurance company for the care you receive. Co-pay is due at the time of service.

In-network insurance:

AETNA PPO
Anthem/Blue Cross Blue Shield
Cigna
Cofinity
Humana
Lucent Health
Medicaid/CHP+
Medicare
Multiplan/PHCS
PNOA (Providers Network of America)
Rocky Mountain Health Plans (RMHP)
UHC PPO/UMR
Veterans/TriWest

If your insurance carrier is not in-network, we cannot directly bill your insurance. You will need to pay the out-of-network cost to receive service with us.

Co-pays are collected at the time of service. We will submit your claim to your insurance company. You will receive a billing statement for any remaining fees not covered by insurance.

Settlement of your bill is required within 30 days of the statement date. If you receive services that are not covered, you will be informed of the cost of the service, and payment will be expected at the time of service.

When you make an appointment, let us know that you have Medicaid, CHP+ or Medicare. Bring your cards with you to your appointment.

Any copays or fees required by Medicaid or CHP+ will be collected at the time of service. If you receive services that are not covered, you will be informed of the cost of the service, and payment will be expected at the time of service.

Need help enrolling Medicaid? Contact our partners at PointCare at 970-372-4908

When you make an appointment, let us know that you have Medicare. Bring your Medicare card with you to your appointment.

Any copays or fees required by Medicare will be collected at the time of service. Your signed acknowledgment of an Advanced Benficiary Notice (ABN) is required, confirming that you will pay for all services not covered by Medicare. If you receive a non-covered service, you will be informed that these services are not covered, and will be patient responsibility.

We are in-network with many dental insurance plans and you will be charged for services according to your individual plan. If you do not have dental insurance and have a current ECH Care Card, you will be charged according to the Sliding Fee Scale. If you have an out of network insurance plan, we will courtesy bill your insurance. We can also offer you a recurring payment plan.

We accept the following dental insurance:

• Aetna
• Anthem
• Cigna
• Dentaquest
• Dentemax
• Guardian
• Humana
• Medicaid
• UHC

We are a provider of the Colorado Dental Health Program for Low Income Seniors. This program provides access to dental care to individuals age 60 and over who are not eligible for dental services under any other dental health care program, such as Health First Colorado (Colorado’s Medicaid Program). Our eligibility staff will screen you for eligibility for this program. As funds for this program are limited, eligibility does not guarantee coverage.