Patient Forms
Downloadable 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 Insurance page for more information)
- Completed new patient paperwork
- Copy of ALL testing and records pertaining to your visit
- CD’s or films
- Reports
- Labs
- Office notes from referring doctor
Prior to your initial visit, we ask that you please download the medical paperwork listed below. Kindly print and fill out the New Patient Paperwork document. There are a total of seven 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 patient forms.
Access New Patient Paperwork and Consent Documents
>> Download New Patient Paperwork <<
Download the interactive .pdf and fill in the rows. Then submit online
>> Print New Patient Paperwork <<
Here is the basic blank .pdf to print and bring into the office.
Secure Upload of Patient Forms in Boulder, CO
We now have a HIPAA-compliant upload feature on our main website. You can upload your completed forms here:
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 HIPAA Acknowledgement Form
Patient History Forms
If you are seeing us for breast health, please fill out the corresponding surgical forms.
Post-Operation Forms
If you are seeing us for any of the following problems, please refer to the corresponding postoperative instructions.
Download Post-Operative Instructions for Breast Biopsy
Download Post-Operative Instructions for Core Needle Breast Biopsy
Requests for Health Information
How do I request a copy of my health information?
Please complete Boulder Breast Center’s Authorization of Medical Record Release form found below and either mail, fax (303-440-7299) or drop it off at Boulder Breast Center. All requests will be processed within five 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 (a 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.
If you have any questions please call 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
Please download Adobe Reader for free if you cannot find the links to the above files.
