Heart Patient Paperwork


Heart Health

 
Please Read Before Downloading The Following Forms:
 
We are pleased you have taken this step towards a proactive role in your health with SHAPE Medical Center. Please complete and return the appropriate forms to our office two full weeks prior to your appointment. Included with our new patient forms is a Release of Medical Records Form. Please fill this out and forward it to any medical provider that may have pertinent medical records. Allow adequate time to get your medical records to us so that we can thoroughly prepare for your visit. Our fax number is 970.549.1176.
 
After each office visit, upon your request, we can provide you with a bill slip. This slip can be attached to the Universal Claim Form (see below) to submit to your insurance for reimbursement, which can vary greatly between insurance companies and individual plans. Blood work and other testing may be covered by your health insurance carrier. Laboratory testing is an integral part of our risk assessment. Be familiar with your medical plan so that you are aware of your out-of-pocket expenses. Claim forms cannot be submitted to Medicare, as this is a non-contracted center.

 
If you are 65 and older, or have Medicare as your insurance, please fill out the Private Medicare Contract.
 
ALL New Patients, please complete the following forms:
 

Patient Demographics

HIPAA Notice of Privacy Practices

Health History

 
If you would like SHAPE Medical Center to release your medical records from our facility to your physician or provider, please complete the Authorization Release For Medical Information.
 
Nutrition and lifestyle factors play an important role in your heart’s health, and because our ultimate goal is your well-being and quality of life, nutrition guidance is part of our program. Please read A Message About Nutrition to gain a better understanding of our approach. You may also be asked to fill out the Food & Exercise Journal.
 
Thank you. We look forward to your visit.

 

Heart Health Paperwork

 

Patient Demographics

Release for Medical Information

Release of Medical Records Form

Universal Claim Form

HIPAA Notice of Privacy Practices

Private Medicare Contract

Health History

Health History Chart