1. This free clinic provides medical care and treatment for basic women’s health concerns.2. The Dream Centers Women’s Clinic is open limited hours and your volunteer or staff provider may have limited office hours.  If you have an emergency health condition, call 911.  If you have an urgent need for care, go to an urgent care facility where you may be seen that day.3. Three incidences of non-compliance (no show to a clinic or specialty care appointment, failure to take medication, failure to comply with treatment recommendations, failure to attend screening appointments or diagnostic study appointments) will be grounds for immediate termination as a patient of the clinic. THREE NO-SHOWS TO APPOINTMENTS WILL RESULT IN REVIEW OF PATIENT STATUS AND POSSIBLE TERMINATION.4. Persons wishing to see a medical provider must have an appointment.5. In order to maintain the clinic schedule, it’s important to arrive on time for your appointment.  If you are more than 15 minutes late, you will need to reschedule.6. Patients will be considered without regard to race, age, religion, national origin, political or union affiliation, marital status, sex or sexual orientation.7. Persons who have private insurance or other medical coverage must notify staff for review of eligibility.8. Medical triage (advice by phone) will generally not be done over the phone.  All patients must have an appointment.

1. Prescriptions will be written, if appropriate, by a provider (nurse practitioner, physician assistant, MD or DO) at the time of appointment.  Dream Centers personnel will refer patients to a prescription assistance program when possible.2. Refill request must be submitted SEVEN DAYS PRIOR TO NEEDED REFILL.  Refills will only be granted on a case-by-case basis and may require an office visit.  We do not refill any emergency medications. 

All Changes to household size, income, address, phone number, and insurance coverage status MUST be reported to the Women’s Clinic within 10 days, Failure to report changes could result in a loss of services.

1. Emergency Room visits even when referred by the Women’s Clinic. 2. Physician, Nurse Practitioner, Physician Assistant Services not authorized by the Women’s Clinic or services outside of the scope of practice of the individual volunteer provider. 3. Maternity Services. 4.Emergency Room follow-up visits.  Patients are encouraged to apply for Colorado Indigent Care Program (CICP) and state and local services.  Patients should follow-up with physician per emergency room instructions. 

1.    CONSENT TO CARE AND TREATMENT – I consent to care, treatment, and diagnostic evaluations performed by the health care providers at the Dream Centers Women’s Clinic. I hereby acknowledge and confirm that I am mentally capable of giving informed consent to the provision of the diagnostics, care and/or treatment and am not subject to duress or undue influence. 2.    HEALTH CARE – I understand that my care, treatment, and diagnostic evaluations will be performed at the direction of my attending physician or health care provider.  It is my attending physician or health care providers responsibility to provide informed consent relation to invasive and medical procedures.  I am aware that the practice of medicine and surgery is not an exact science and acknowledge that no guarantees have been made as to outcome of the care provided.  3.    RELATED RELEASE OF INFORMATION – Dream Centers Women’s Clinic may release medical and other information about me in accordance with Dream Centers Women’s Clinic’s privacy practices as described in it’s Notice of Privacy Practices.  I may request a copy of this notice from Dream Centers Women’s Clinic at any time. 4.    AGREEMENT TO PAY AND GURANTEE – I understand that my visit is free, but that I may be charged by providers for laboratory and other ancillary services received outside of the Dream Centers Women’s Clinic. I may also be responsible for pharmaceuticals obtained from pharmacists outside of Dream Centers Women’s Clinic.  I understand that my signature indicates agreement with this Treatment and Consent. 5.    PERSONAL VALUABLES – I understand that Dream Centers Women’s Clinic will not be responsible for the loss or damage to my property, articles of value, cell phones or money.  Dream Centers Women’s Clinic strongly recommends that items of value or money be left at home or given to a family member or bring items into the examination room with you.  Upon leaving the clinic, I will remove all of my property.  I understand that property left at Dream Centers Women’s Clinic will be kept in a lost and found for safe keeping until I can claim it. Or up to one month after my visit. 6.    IMMUNITY – Medical care or treatment at Dream Centers Women’s Clinic may be provided by individuals who are volunteer health care providers.  They are legally and professionally licensed and are not employed by the Dream Centers Women’s Clinic 7.    HIPAA & Privacy Practices – Please see documents provided at the front desk for more information. 8.    SHARING OF INFORMATION – Please list family members or other persons, IF ANY, whom we may inform about your general medical condition, your diagnosis, treatment, etc.  These will be the only people we will be able to speak to our release any information regarding your medical record/account. 

To be provided to the individual patient before health care services are provided, except inemergency cases when notice may be provided as soon after the emergency as ispracticable or to a parent or legal guardian when the patient lacks legalresponsibility for his/her care under State law. This is to notify you thatunder Federal law relating to the operation of free clinics, the Federal TortClaims Act (FTCA), (See 28 U.S.C. §§ 1346(b), 2401(b), 2671-80) provides theexclusive remedy for damage from personal injury, including death, resultingfrom the performance of medical, surgical, dental, or related functions by anyfree clinic volunteer health care practitioner, board member, officer,employee, or independent contractor who the Department of Health and HumanServices has deemed to be an employee of the Public Health Service. This FTCAmedical malpractice coverage applies to deemed free clinic volunteer healthcare practitioners, board member, officer, employee, or independent contractorwho have provided a required or authorized service under Title XIX of theSocial Security Act (i.e., Medicaid Program) at a free clinic site or throughoffsite programs or events carried out by the free clinic (See 42 U.S.C. §233(a), (o)). Protection Act of 1997 may cover certain free clinic health careprofessionals providing health care services to patients at this free clinic.