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Enrolling in Appleton Clinics is quick and easy using this secure form.

If you prefer, call (970) 985-7110 to speak with an enrollment specialist and enroll over the phone or in person.
Each adult membership is $99 per month, collected automatically from your credit or debit card. Receive two months free if paying annually.
Adult members may add up to two children 25 & under free per family. Additional children are only $10 per month each.
A one-time $99 registration fee per adult will be included in your total initial charges.
You may cancel at any time.

We do not deny membership for pre-existing conditions or lack of insurance coverage. Clinic space is limited. Once you submit this application and complete your medical history form(s) we will contact you if we have any questions or concerns about our physician’s ability to properly care for you given your particular healthcare needs and our current patient capacity. If for any reason your membership is not accepted, we will refund your $99 enrollment fee(s).

Basic Contact Information

First Name * Middle Name (or initial) Last Name * Date of Birth * Sex * Nickname/Preferred Name

Home Address

Address 1 * Address 2 City * State * ZIP Code *

Contact Information

Home Phone Number * Work Phone Number Mobile Phone Number Preferred Contact Number Email Address Confirm Email Address I don't have an email address

Emergency Contact

Emergency Contact First Name * Emergency Contact Middle Name Emergency Contact Last Name * Relationship to Patient Emergency Contact Phone Number *

Set Username and Password for Patient Portal

To gain online access to your medical records and secure communications, please create a username and password that you will use to log into the patient portal in the future.

Your username must be at least 4 characters long.
Each participating member on your account must have a unique username and password.

Username *

Your password must be at least 8 characters long and include at least one number or special character.

Password * Confirm Password *

Billing

Credit/Debit card monthly auto-payment required for membership fees.

SECURELY provide card info online here Provide card info later in-person or by phone

PLEASE CHOOSE your preferred billing frequency.

Bill Monthly ($99 per adult) Bill Annually (two months free, non-refundable, $990 per adult)

Card Details

Card Billing Address

First name on card * Last name on card * Billing Address * Zip/Postal Code * State/Province *

When would you like your membership to start?

"I have read, understand and accept the terms of the Appleton Clinics Privacy Policy below:" *

The Notice explains how we fulfill our commitment to respect the privacy and confidentiality of your protected health information. This Notice tells you about the ways we may use and share your protected health information, as well as the legal obligations we have regarding your protected health information. The Notice also tells you about your rights under federal and state laws. The Notice applies to all records held by Appleton Clinics GJ, LLC's facilities and programs, regardless of whether the record is written, computerized or in any other form. We are required by law to make sure that information that identifies you is kept private and to make this Notice available to you.

Your Rights

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

Get a copy of your paper or electronic medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Correct your paper or electronic medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communication
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit the information we share
- You can ask us not to use or share certain health information for treatment, payment, or our operations.
  - We are not required to agree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
  - We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared your information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you believe your privacy rights have been violated
- You can complain if you feel we have violated your rights by contacting us using the information in this notice.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to
  
  200 Independence Avenue, S.W.
  Washington, D.C. 20201
  by calling 1-877-696-6775, or visiting HHS.GOV Complaints .
- We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us what to share
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising
- We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
- We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
- We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: HHS.GOV consumer home .

Help with public health and safety issues
- We can share health information about you for certain situations such as:
  - Preventing disease
  - Helping with product recalls
  - Reporting adverse reactions to medications
  - Reporting suspected abuse, neglect, or domestic violence
  - Preventing or reducing a serious threat to anyone's health or safety
Do research
- We can use or share your information for health research
Comply with the law
- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law
Respond to organ and tissue donation requests
- We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
- We can use or share health information about you:
  - For workers' compensation claims
  - For law enforcement purposes or with a law enforcement official
  - With health oversight agencies for activities authorized by law
  - For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or in response to a subpoena

Electronic Access

We provide electronic access to your health information via the Cerbo Patient Portal.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: HHS.GOV consumer notice .

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This notice is effective as of 11/21/2024.

I have read and understand the Services Agreement below:

Appleton Clinics GJ, LLC, through its Physician(s), agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement.

Patient. A patient is defined as those persons for whom the Physician(s) shall provide Services, and who are signatories to, or listed on the enrollment form that is incorporated by reference in this Agreement.
Services. As used in this Agreement the term Services shall mean a package of services, both medical and non-medical, and certain amenities (collectively "Services"), offered by Appleton Clinics, subject to change without further notice and further described at AppletonClinics.com and the Patient Registration Form (attached as Appendix 1).
Fees. In exchange for the services described herein, Patient agrees to pay Appleton Clinics the amounts as set forth in the Patient Registration Form. These fees are payable upon execution of this Agreement, and are in payment for the services provided to Patient during the term of this Agreement. If this Agreement is cancelled by Appleton Clinics before the Agreement termination date, then Appleton Clinics shall refund the Patient's prorated share of the original payment remaining after deducting individual charges for services rendered to Patient up to cancellation. If Patient cancels this Agreement, no refunds will be given. In any event, no refunds will be given for registration fees paid.
Non-Participation in Insurance. Patient acknowledges that neither Appleton Clinics nor the Physician(s) participate in any health insurance or HMO plans or panels and all have opted out of Medicare. Neither of the above make any representations whatsoever that any fees paid under this Agreement are covered by any health insurance or other third party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign a Medicare opt-out agreement, and incorporated by reference. This agreement acknowledges your understanding that the Physician has opted out of Medicare, and as a result, Medicare cannot be billed for any services performed for you by the Physician. You agree not to bill Medicare or attempt Medicare reimbursement for any such services. Patient shall renew and sign the opt-out agreement each year.
Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage (such as membership in an HMO). Appleton Clinics will not cover hospital services, specialist visits, emergency room visits, surgeries, advanced radiology and imaging, worker’s compensation claims or any other services not personally provided by Appleton Clinics or its Physicians. Patient acknowledges that Appleton Clinics has advised that patient obtain or keep in full force such health insurance policy (ies) or plans that will cover Patient for general healthcare costs. Patient acknowledge that this Agreement is not a contract that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.
Medical Services. As used in this Agreement, the term Medical Services shall mean those medical services that the Physician himself is permitted to perform under the laws of the State of Colorado and that are consistent with his training and experience as a family medicine physician, as the case may be. A list of current services offered is available at AppletonClinics.com and is subject to change without further notice.
Availability. The Physician may, from time to time, due to vacations, sick days, and other similar situations, not be available to provide the services referred to above in this paragraph 6. During such times, Patient's calls to the Physician, or to the Physician's office, will be directed to a licensed medical provider who is "covering'' for the Physician during his absence. Appleton Clinics will make every effort to arrange for coverage but cannot guarantee such coverage.
Pharmacy services. Appleton Clinics has an on-site limited pharmacy. Patient is free to fill prescriptions at any pharmacy of their choice. If Patient elects to have the prescription filled at Appleton Clinics, the cost of the medication will be charged to Patient and collected as any other fees are collected. Appleton Clinics will not bill any insurance or other entity for medication costs.
Third-Party Referrals and Preferred Rates. Physician may elect to coordinate with third party medical specialists to whom Patient is referred and may assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialists’ fees or fees due to any third-party medical professional other than the Appleton Clinics Physician(s). In the event Appleton Clinics is able to negotiate a preferred rate on behalf of Patient for third party services (including, but not limited to advanced imaging, specialist visits, laboratory work, hospitalizations and other third-party medical services), and such preferred rates require Appleton Clinics to collect payment for services on behalf of the third party, such payments shall be paid by You to Appleton Clinics in advance of Patient receiving such services. Any such payments on behalf of a Patient do not create any obligation on behalf of Appleton Clinics other than to pay the third party provider. Patient is under no obligation to use such referrals.
Term; Termination. This Agreement will commence on the date first written above and will extend monthly thereafter. Notwithstanding the above, both Patient and Appleton Clinics shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving 30 days’ prior written notice to the other party. Unless previously terminated as set forth above, at the expiration of the initial one-month term (and each succeeding monthly term,) the Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee for the contract month.
Electronic Communications. You acknowledge that communications with the Physician using e-mail, facsimile, video chat, texting instant messaging and cell phone (collectively, “Electronic Communications”) are not guaranteed to be secure or confidential methods of communications. As such, You expressly waive the Physician's obligation to guarantee confidentiality with respect to correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical records. Patient authorizes Appleton Clinics, and its Physicians to communicate with Patient by Electronic Communications regarding Patient's "protected health information" (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations).

Patient further acknowledges that:

Electronic Communications are not necessarily secure mediums for sending or receiving PHI and, there is always a possibility that a third party may gain access;
Although Appleton Clinics and the Physician will make all reasonable efforts to keep Electronic Communications confidential and secure, neither Appleton Clinics nor the Physician can assure or guarantee the absolute confidentiality of Electronic Communications;
In the discretion of the Physician(s), Electronic Communications may be made a part of Patient's permanent medical record; and,
Electronic Communications are not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which Patient could reasonably expect to develop into an emergency, Patient shall call 911 or the nearest emergency room, and follow the directions of emergency personnel.
If Patient does not receive a response to an Electronic Communication within one day, Patient must use another means of communication to contact the Physician(s). Neither Appleton Clinics nor the Physician(s) will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of technical failures, including, but not limited to,
1. technical failures attributable to any internet service provider,
2. power outages, failure of any electronic messaging software, or failure to properly address e-mail or text messages,
3. failure of the Clinic’s computers or computer network, or faulty telephone or cable data transmission,
4. any interception of Electronic Communications by a third party; or
5. your failure to comply with the guidelines regarding use of Electronic Communications as set forth in this paragraph.
Change of Law. If there is a change of any law, regulation or rule, federal, state or local, that affects the Agreement including these Terms & Conditions, that are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party's rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.
Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of this Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and if Appleton Clinics is therefore required to refund all or any portion of the monthly fees paid by Patient, Patient agrees to pay Appleton Clinics an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
Amendment. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, Appleton Clinics may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation ("Applicable Law") by sending You 30 days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by Appleton Clinics, except that Patient shall initial any such change at Appleton Clinics’ request. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.
Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
Relationship of Parties. Patient and the Physician(s) intend and agree that the Physician(s), in performing his/her duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Physician(s) shall have exclusive control of his/her work and the manner in which it is performed.
Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.
Miscellaneous. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
Entire Agreement. This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.
Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Colorado and all disputes arising out of this Agreement shall be settled in the District Court of Mesa County, Colorado.

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Join Us

Basic Contact Information

Home Address

Contact Information

Emergency Contact

Set Username and Password for Patient Portal

Billing

Card Billing Address

How did you hear about Appleton Clinics?

Authorization

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

Get a copy of your paper or electronic medical record

Correct your paper or electronic medical record

Request confidential communication

Ask us to limit the information we share

Get a list of those with whom we've shared your information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint if you believe your privacy rights have been violated

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us what to share

In these cases we never share your information unless you give us written permission

In the case of fundraising

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

Run our organization

Bill for your services

How else can we use or share your health information?

Help with public health and safety issues

Do research

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

Address workers' compensation, law enforcement, and other government requests

Respond to lawsuits and legal actions

Electronic Access