Other Forms

1. Home
2. Patient Support
3. Patient Forms
4. Other Forms

Colorado Retina Policies

• Good Faith Estimate

• Good Faith Estimate (Spanish)

• HIPAA Policy

• Notice of Privacy Practices

• Notice of Privacy Practices (Spanish)

• Financial Policies

• Financial Policies (Spanish)

• Communication Consent

• Communication Consent (Spanish)

• Patient Code of Conduct

• Patient Code of Conduct (Spanish)

View Notice of Privacy Practices

Co-pay Assistance Enrollment Forms

Financial assistance is available for certain intravitreal injection treatments, for eligible patients.

• EYLEA4U Patient Enrollment Form

• EYLEA4U Patient Enrollment Form (Spanish)

• Ozurdex Patient Enrollment Form

• Syfovre - Apellis Assist Enrollment Form | Apellis Assist

• Lucentis, Vabysmo, Susvimo

Payment Assistance and Grants

Good Days and other payment assistance programs provides financial support for patients who cannot afford the ocular treatment they urgently need. Contact one of our financial counselors at 303-261-1600 for more information.

• Hardship Application

• Hardship Application (Spanish)

• Good Days

Language Assistance Services

Free virtual language interpreting services are available for your appointments if your primary language is not English. We offer support in Spanish, Chinese, Vietnamese, Korean, Russian, German, French, Japanese, and over 15 other languages.

• Language Assistance

Continuous Care Program

Your whole body is connected. Your care plan should be, too. We offer a Continuous Care Program that meets your unique retina and general healthcare needs. More info HERE.

• CCP Informational Brochure

• CCP Enrollment Form

• CCP Enrollment Form- Spanish

LumiThera Photobiomodulation

Informed Consent Form required for patients to sign before enrolling in LumiThera's Valeda photobiomodulation (red light) treatment.

• Valeda Informed Consent