Patient Forms

Agreements and Policies

Patient Rights and Responsibilities

It is important to know your rights as a patient and also your responsibilities. The staff and personnel of Premier Eye Surgery Center recognize the basic human rights and responsibilities of our patients. Efforts are directed to providing care consistent with those basic human rights and...


Notice of Privacy Practices

  • Our Notice of Privacy Practices informs you on our Uses and Disclosures of: Treatment, Payment, Health Care Operations, Law Enforcement, Public Health reporting, Appointment Reminders, Information About Treatment, and Other uses....


Complaint & Grievance Procedure

We pride ourselves on creating a healing environment for our clients with exceptions care. However, if for any reason you have a complaint or a grievance about any of our services provided, we ask that you contact one of our patient representatives.


Disclosure of Ownership

Premier Eye Surgery Center is a physician-owned entity in partnership with Boulder Community Health.

The following physicians have ownership: Dr. Donald Keller, Dr. Brian Nichols, Dr. Kevin Cuevas, Dr. Richard Stewart, Dr. Geeta Lalwani, Dr. Robert Courtney, and Dr. Mohammad...


Admission Forms

Acknowledgement of Agreements and Policies

I have read and reviewed the following documentation and offered/received a copy of:

  • Rights & Responsibilities
  • Notice of Privacy Practice
  • Complaint & Grievance
  • Disclosure of Ownership

Acknowledgment of Advance Directive Policy

All patients have the right to participate in their own health care decisions and to make advance directives or to execute powers of attorney that authorize others to make decisions on their behalf based on the patient’s expressed wishes when the patient is unable to make decisions or unable to...


Patient Financial Responisiblity Agreement

Patient Responsibility

Any fees collected at the time of service and any quotes regarding such fees are estimated based on the information available to us at the time of service. We rely on information provided by the responsible party regarding insurance...


Your Rights and Protection Against Surprise Billing Act

Beginning January 1,2020, Colorado state law protects you from Surprise Billing,” also known as Balance Billing.” Also beginning January 1, 2022, Federal law protects you from “surprise billing” and “balance billing.”