Becoming a Patient at MarillacHealth
Thank you for your interest in becoming a patient at MarillacHealth. Below is the New Patient Registration Form to print and drop off or mail in OR the option to complete an online fillable form, Docusign. To apply for a sliding scale discount you must provide information in the Financial Assistance Packet. You can download the form in Spanish or English using the links below, or pick one up at one of the MarillacHealth locations in Grand Junction (6th Street Clinic: 2333 N. 6th Street near St. Mary’s Hospital, 12th Street Clinic: 2139 N. 12th Street in the 12th Street Plaza, or at the 29.5 Road Clinic: 510 29 1/2 Road at Mesa County Public Health) or in Montrose (87 Merchant Dr, Montrose, CO 81401).
Financial Assistance Packets (Asistencia Financiera Solicitud de Elegibilidad-Español)
English Español
Patient Registration Form (Formulario de registro de pacientes)
CARING FOR YOU AND YOUR FAMILY
We at MarillacHealth appreciate the opportunity to care for you and/or your family. Whether you need a routine physical exam, prenatal care, help managing your diabetes or depression, or dental care, you can trust us for high quality affordable service.
Schedule An Appointment
Before you are seen by one of our providers, we will need some basic information. If you have health insurance or dental insurance; Medicaid, and/or Medicare Advantage Plans, call our appointment center and they will be able to schedule an appointment for you.
Registration Forms
There are two options to complete your registration paperwork. You may complete these forms securely online with DocuSign; or, you may print a PDF of the form, fill out, and either drop off at the clinic at least 24 hours prior to your appointment OR fax to 970-200-1611.
Medical Forms – Grand Junction
Medical Forms – Montrose
Dental Forms
If You Don’t Have Health Insurance
If you do not have health insurance, you may qualify for one of our discount programs that will allow you to access health care at discounted rates. See our page on Uninsured information. You will be asked to meet with one of our Eligibility Specialists to determine if you and/or your family qualify for the programs based on family size and income.
One of our Eligibility Specialists can explain the details of applying for our sliding fee programs. You must provide proof of income to apply for the programs and bring your picture ID.
You might also be interested in reviewing options to purchase insurance on the Connect For Health Colorado Insurance Marketplace. You can schedule an appointment with a Certified Guide at either MarillacHealth or Hilltop Health Access (our partner) by clicking here.
Personal Details
Our friendly staff will help you make your medical or dental appointment. You will be asked to provide your name, address, phone number, date of birth (DOB) and insurance information.
At your first appointment, please arrive 15 minutes early to complete the registration form and health history information. Please bring your private insurance card, Medicaid card, Medicare card or Marillac Sliding Fee Discount Card along with a picture ID.
Click To See Our Sliding Fee Discount Schedule
Click to see a list of cash pay prices (fees) for the 15 most common health care services. This is per Colorado law SB17-065 Transparency in Direct-Pay Health Care Pricing.
Billing Questions
Please direct questions about your bill to our Billing Department by calling 970-697-4603.
You can also fax questions to 970-692-8301.
Patient Account Representatives are available from 8:00 AM – 5:00 PM, Monday through Friday.
