Alpine Surgical

Richard J. Fox, MD FACS

Foothills Medical Building
4745 Arapahoe, Suite 300
Boulder, CO 80303
Phone: 303-449-3642
Fax: 303-440-7299

Specialists in General, Vascular, Thoracic, and Minimally Invasive Surgery

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 (see below)

Prior to your initial visit, we ask that you please print and fill out the Patient Information Form. There are 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.

Please print this form SINGLE SIDED.

NEW PATIENT INFORMATION FORMS

Please read this policy prior to your visit and sign the last page of the above packet.

HIPAA - NOTICE OF PRIVACY PRACTICE

Please feel free to print a copy of our financial policy for your records.

ALPINE SURGICAL FINANCIAL POLICY

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

BREAST HEALTH HISTORY FORM

GALLBLADDER HEALTH HISTORY FORM

HEMORRHOID HEALTH HISTORY FORM

HERNIA HEALTH HISTORY FORM

THYROID/PARATHYROID HISTORY FORM

VEIN/LEG PAIN HISTORY FORM

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

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Goodbye Vein,
Goodbye Pain!
Remove varicose veins
in one simple office
procedure.

Laparoscopic
Hernia Surgery
Providing quick return to
your busy schedule.

Navigating Breast
Cancer
Helping you through
your difficult process.

Patient Forms

Billing and Insurance

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