Patient Forms

To better serve you, please bring the following items to your visit:

  • Insurance Card(s) and Photo ID
  • Physician Referral (if you have one)
  • Co-pays, Co-Insurance, Unmet Deductibles that apply to your office visit
  • (See “Billing and Insurance” for more information)
  • Copy of ALL testing and records pertaining to your visit
    • CD’s or Films
    • Reports
    • Labs
    • Office Notes from Referring Doctor

Completed patient forms

Prior to your initial visit, we ask that you please print and fill out the Patient Information Form. There is a total of 7 pages. Please fill out all of them to the best of your ability. If you have a medication or surgery list please attach it to your forms.

New Patient Information Forms

Please print this form SINGLE SIDED.

Download New Patient Form

HIPAA – Notice of Privacy Practice

Please review the HIPAA policy below prior to your consultation. Be sure to sign the HIPAA acknowledgment form confirming you have read this document.

Download Privacy Statement

Download HIPAA Acknowledgement Form

Patient History Forms

If you are seeing us for any of the below-stated problems, please fill out the corresponding form.

Download Breast History Form

Download Gallbladder History Form

Download Hemorrhoid History Form

Download Hernia History Form

Download Thyroid-Parathyroid History Form

Download Vein History Form

Pre-Operation Forms

If you are seeing us for any of the below stated problems, please fill out the corresponding form.

Download Pre-Operative Instructions for Vein Procedure

Post-Operation Forms

If you are seeing us for any of the following problems, please see the corresponding post operative instructions for your reference.

Download Post Operative Instructions for Appendectomy

Download Post Operative Instructions for Breast Biopsy

Download Post Operative Instructions for EVLT

Download Post Operative Instructions for Hemorrhoidectomy

Download Post Operative Instructions for Inguinal Hernia

Download Post Operative Instructions for Laparoscopic Cholecystectomy

Download Post Operative Instructions for Ports

Download Post Operative Instructions for Thyroid or Parathyroid

Download Post Operative Instructions for Umbilical or Ventral Hernia

Requests for Health Information

How do I request a copy of my health information?

Please complete Alpine Surgical’s Authorization of Medical Record Release form found below and either mail, fax (303.440.7298) or drop it off at Alpine Surgical.  All requests will be processed within 5 business days after receiving a completed form and any additional information required.

Who is authorized to sign the release for my health information?

  • Patient (Not your Spouse or Partner)
  • Power of Attorney (Legal Documentation must be provided with request)
  • Parent (if the patient is younger than 18).
  • Legal Guardian (Legal Documentation must be provided with request)
  • A representative of the estate for deceased patients (Copy of the death certificate and documentation detailing Representative must be provided with the request).

How much does it cost to obtain a copy of my health information?

There is no charge for releasing copies of health information directly to other health care providers or other entities identified under HIPAA.

Patients that are requesting a copy of their information will be charged for copies of their records.  The fees are as follows:

Pages 1-10 $10.00
Pages 11-25 $25.00
Pages 26+ $35.00

If you have any questions please contact our office at 303‑449‑3642.

If you would like to get a copy of your medical records sent to us or another office, please fill out the release form below and mail, fax or drop off at our office.

Authorization of Medical Record Release

Authorization to discuss medical and billing information with family/friends

Additional Forms

Instructions to log onto Patient Portal

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