New Patient Registration Form

  • Patient Demographics

    Please bring a photo ID with you at the time of your appointment
  • Insurance Information

    Please bring a copy of your insurace card with you to your appointment
  • (If applicable)
  • Personal Health History

    Please be as detailed as possible when filling out the below information.
  • Please list any other conditions you may have that are not listed above.
  • Please Identify any other medical providers you see; including name of the physician or practice, their specialty, and a contact phone number.
  • Please be as specific as possible as to who was diagnosed with what condition.
  • Acknowledgement of Receipt of Notice of Privacy Practices

    We would like to thank you for choosing Altitude Family and Internal Medicine as your medical provider. We are happy that you have decided to “take your health to a higher level™.” We would like to keep you informed regarding current office policies. This policy may change at any time without notice; an updated copy will always be available at our facility and online. Relationship: Applying to be a new patient does not mean that you will be accepted as a patient. No Doctor-Patient relationship exists until you have been seen by one of our medical providers for an initial appointment, your medical history including prior medical records has been reviewed, and the facility agrees to accept you as a patient. We value the relationship that we establish with you. We encourage you to see the same clinician visit-to-visit to ensure the best quality and continuity of care. Office Hours: Our facility is open Monday through Thursday from 8:00am -5:00pm and Friday 8:00 am to 4:00 pm. We are closed from 12:00 pm to 1:00 pm for lunch. Urgent and Emergent needs: We understand that you may have unforeseen urgent or emergent medical issues. If you are having an emergent issue: please call 911. If your needs are less emergent, or more urgent in nature, please call our receptionist and inform them of your urgent needs. You will be triaged by one of our excellent nursing/assistant staff immediately when you call. They will determine, with the assistance of a medical provider, the appropriate course of action. Communication: Your Physicians, Mid-Level Providers, Nurses, and Medical Assistants are all an integral and collaborative part of your Health Care Team at Altitude Family and Internal Medicine. Phone calls during business hours are typically answered by our trained staff. This enables our providers to spend more time with patients in the office. In the event our staff cannot address your concerns, they will consult with your provider and return your call as soon as possible. Our staff answers the phone calls throughout the day, as patient volume dictates. All of our staff check their voicemail at the beginning of each day, the end of the morning, and the end of the day. All of the phone messages are returned, at the latest, by the end of each day. You may also contact us by e-mail at . Please note that e-mail should not be used for urgent issues – please call our office to discuss urgent issues. Also, please note that in certain instances we may not be able to contact you by e-mail due to privacy reasons, and will therefore contact you by phone. E-mails are checked regularly and you can expect a return e-mail within 48 hours after receipt. Same-Day Appointments: We know that not all visits with us can be scheduled in advance. We have specific appointments that are always held for same-day availability and need. After Hours Emergencies: For a serious emergency, please go to the nearest Emergency Room or call 911. Our providers are available after hours for other urgent issues and may be paged by calling our main number, 303-730-2167 and following the instructions you will be given. The medical provider will answer your call within 30 minutes after leaving your name and number. Non-urgent or inappropriate after hours calls may incur a charge that is not covered by your insurance company. Cancellations and Missed Appointments: Please call our office at least 24 hours in advance if you are unable to keep your appointment time. Any patient who fails to notify at least 24 hours in advance or fails to show up for their appointment may incur a $50 charge for a regular office visit and $100 for a wellness exam that is not covered by your insurance company. Timeliness: We ask that you arrive a few minutes prior to your appointment time, as we do our very best to keep the schedule. If you are more than a few minutes late for your appointment, your appointment time may be changed to the next available appointment, depending on our schedule. We ask that you respect our provider’s time, as we respect yours in trying to see every patient in a timely manner. At Altitude Family and Internal Medicine, we consistently outperform the national averages with respect to wait times. However, it is also important to us that we put quality patient care ahead of schedules. Sometimes this means that our patients may have to wait if their provider has gotten behind with an unexpected emergency, a complex condition, or an unanticipated complication. We know your schedule is busy and that your time is valuable. If this situation arises, we will inform you of the delay and will offer a solution, whether that be visiting with another provider or rescheduling your appointment to a later time. In order to maintain our schedule, please understand that your appointment does have a time limit. We are happy to address your complaint for that day, but multiple complaints that require extensive amounts of time may require more than one appointment time. If your appointment runs 10 min over, we are then late for all of the following appointments, which is unfair to those patients who deserve the same time and respect we have shown to you. Also, please remember that we are running several different schedules; if someone who arrived after you is called before you, they might be having blood drawn or be seeing another provider. Treatment of Minors: Patients under the age of 18 must be accompanied by a responsible adult or have written permission for treatment from a parent or guardian. Assigning a PCP: You are responsible for assigning Dr. Doug Hansen or Dr. Jill Quigly as the Primary Care Provider on your insurance policy prior to being seen in our office. If PCP assignment is required by your insurance carrier and you fail to comply, you will be responsible for all charges from our facility that are denied by your insurance carrier. Payment: Copays and coinsurance are due at the time of your visit. This policy is based on federal regulations established by the U.S. Department of Health and Human Services. Please see our billing FAQ for further information. We accept cash, major credit cards, and debit cards for payment. Insurance and Insurance Billing: At Altitude Family and Internal Medicine, we understand how complicated and confusing medical billing processes and the statements you receive may seem. We are happy to bill your insurance company for the services you receive as a courtesy to you. As a courtesy, we will file all claims for our service with your primary insurance company. If you have Medicare, we will automatically file a claim with your secondary insurance as well. Once we know your insurance has paid in full on their portion of the bill, the remaining balance of the bill will become the patient’s responsibility and accordingly an invoice will be sent. Services billed on your behalf are provided to you on a credit, with no guarantee your insurance will cover any or all services provided. Please be advised that the ultimate financial responsibility for services provided does not belong to your insurance company, but to the person receiving the services or their guardian. Your medical insurance policy is a contract between you and the insurance carrier. By law, Altitude Family and Internal Medicine is not a party to that contract. Your coverage, the requirements for pre-authorization, pre-certification, specialist consultation, deductibles, co-payments and co-insurance are all defined in your policy. You are responsible for reading, understanding, and following the procedures outlined in your policy handbook. We will be happy to assist you when and where we can with specific questions and concerns. Your employer, insurance agent, or the federal government determines the range of benefits eligible to you. Please see our billing FAQ for further information. Patients without Insurance: Payment in full is due at the time of service. We do provide discounted pricing to our non-insured patients for paying at the time of service. In the interest of transparency and disclosure, we have compiled a list of the most common office charges available for your review. We work closely with outside agencies that provide low-cost or no-cost radiology and laboratory services. Motor Vehicle Accidents (MVA) and third-party liability: We do not file charges to MVA insurance policies, attorneys, or any other third party. All charges for services rendered in these instances are payable in full at the time of your visit. You will need to submit your charges and seek reimbursement from the third party. The exception to this policy is that we will bill workers’ compensation insurance on your behalf. Prescriptions: Typically, you will be given an appropriate amount of medicine and/or refills to get you to your next recommended appointment; therefore the best time to get a prescription refill is at your next appointment. We do realize that occasionally, however, you will need a refill prior to your next scheduled appointment. In this case, refills should be requested from your pharmacy who will then contact us for authorization. Please do not wait until you have run out to request refills, as it may take 72 hours to process the request. Prescriptions and refills will not be authorized outside of normal business hours. Antibiotics: We believe that antibiotics are important for a number of medical conditions. It is important that all potential infections be carefully evaluated; therefore antibiotics cannot be prescribed without a face-to-face evaluation in our office. Narcotics: We believe that narcotics are good for a limited number of problems. Narcotics will not be routinely prescribed for long term use. If you have a need for chronic narcotics or have narcotic dependence, we will be happy to refer you to a pain specialist. Lab and Diagnostic Test Results: At Altitude Family and Internal Medicine we do not subscribe to the old adage that “no news is good news.” We believe that all of our patients should take charge and be informed of their health, and we recommend that you schedule a follow-up appointment 10-14 days after testing to review your results in detail. Alternatively, for complete physical exams we recommend that you schedule your blood draw 10-14 days in advance so that we can discuss your results at your physical. If a follow up appointment is not scheduled, routine laboratory and test results will be reported within 10-14 days of testing. If you have not heard from us in this time frame, we ask that you call our office to request your results. Urgent and STAT labs and tests will be reported to you as soon as we receive them. In these cases please make sure that we have a way to get into immediate contact with you. Referrals: Referrals are completed as soon as possible, and are typically transmitted to your insurance and/or specialist on the same day as your appointment with us. Additionally, you will receive the specialist’s name and telephone number from our office that same day; if you do not please ask for that information. As a patient, it is your responsibility to ensure that your specialist is on your insurance plan. It is also your responsibility to ensure your specialist receives any test results that they may need. Please understand that it can sometimes take a week or longer for your referral to be approved by your insurance company and that it may take several weeks to get an appointment with a specialist. This is not something that we have control over. Complete Physical Exams: We believe that routine, annual complete physical exams with screening lab tests are very important for good health and the cornerstone of prevention. However, insurance benefits may vary. Some policies cover “wellness” and others cover visits when you have a complaint. Please learn about your benefits prior to your appointment so you will know what is covered by your insurance plan. Language: We want to provide the best service to you and your loved ones. In the case that you do not speak English, we do use a translator service to help us better communicate with you. We do ask, that you bring with you someone who also can help translate as to ensure the best care of you. Health insurance issues and questions: We believe in helping our patients navigate through this complex medical system as best as possible. We have a number of resources available to those with and without insurance. We counsel you individually to see what needs you have and what services you are eligible for. We work closely with the health department and Quest diagnostics. Privacy: This office is required by law to maintain the privacy of our patients and provide individuals with a notice of our legal duties and privacy practices with respect to protected health information. A copy of the HIPAA Privacy Policy Statement of Altitude Family and Internal Medicine is available for your review and if you would like you may have a copy for your records. Altitude Family and Internal Medicine may use and share your confidential health information with others in order to treat you, to arrange for payment of your bill, and for issues that concern Altitude’s operations and responsibilities including but not limited to: • Communicating to appropriate individuals (using our best judgment) in the event of an emergency • Disclosing adverse events to the FDA • Complying with laws regarding workers’ compensation claims • Reporting to the department of public health or health oversight agencies as required by law • Reporting abuse or neglect as required by law • Reporting to correctional institutions for the health and safety of other individuals • Reporting to law enforcement agencies as allowed or required by law • Reporting for judicial or administrative proceedings as allowed or required by law • Disclosing information to researchers when an institutional review board has reviewed a research proposal, approved the research and established protocols to ensure the privacy of your protected health information Additionally, in cases of fraudulent or diversionary behavior, you may lose your right to protection of your health record, and our record in its entirety may be turned over to the appropriate law enforcement agency. Dismissal: If you are “dismissed” from the practice, it means you can no longer schedule appointments, get medication refills, or consider us to be your medical provider. You will have to find a medical provider in another practice. We will notify you personally and/or send a letter to your last known address notifying you that you are being dismissed. If you have a medical emergency within 15 days of the date of dismissal, we will see you. After that, you must find another doctor. We will forward a copy of your medical record to your new doctor after you let us know who they are and sign an approved release form. Common reasons for dismissal include: • Fraudulent behavior, such as failure to be honest and forthcoming with your medical history or in notifying us of other physicians that you have or are currently seeing • Failure to keep appointments, excessive cancellations, or excessive tardiness • Noncompliance on medical issues or practice policies and procedures • Inappropriate conduct, including disrespectful or abusive behavior towards our staff • Failure to pay your bill In cases such as verbal or physical threat of any type, the incident will be reported to local law enforcement and the appropriate charges will be filed. Concerns: At Altitude Family and Internal Medicine, it is our mission to provide excellent, comprehensive, and coordinated patient-centered medical care. We take all patient concerns seriously. If you have any questions regarding any of our patient policies and procedures, or have concerns with any part of our practice, we ask that you submit them in writing either on paper or by e-mail to

    This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. Your medical record may contain personal information about your health. This information may identify you and relate to your past, present or future physical or mental health condition and related health care services and is called Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment. How we may use and disclose health care information about you: FOR CARE OR TREATMENT: Your PHI may be used and disclosed to those who are involved in your care for the purpose of providing, coordinating, or managing your services. This includes consultation with clinical supervisors or other team members. Your authorization is required to disclose PHI to any other care provider not currently involved in your care. Example: If another physician referred you to us, we may contact that physician to discuss your care. Likewise, if we refer you to another physician, we may contact that physician to discuss your care or they may contact us. FOR PAYMENT: Your PHI may be used and disclosed to any parties that are involved in payment for care or treatment. If you pay for your care or treatment completely out of pocket with no use of any insurance, you may restrict the disclosure of your PHI for payment. Example: Your payer may require copies of your PHI during the course of a medical record request, chart audit or review. FOR BUSINESS OPERATIONS: We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. We may also disclose PHI in the course of providing you with appointment reminders or leaving messages on your phone or at your home about questions you asked or test results. Example: We may share your PHI with third parties that perform various business activities (e.g., Council on Accreditation or other regulatory or licensing bodies) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. REQUIRED BY LAW: Under the law, we must make disclosures of your PHI available to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule, if so required. WITHOUT AUTHORIZATION: Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. Examples of some of the types of uses and disclosures that may be made without your authorization are those that are: • Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the health department) • Required by Court Order • Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. VERBAL PERMISSION: We may use or disclose your information to family members that are directly involved in your receipt of services with your verbal permission. WITH AUTHORIZATION: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. Your explicit authorization is required to release psychotherapy notes and PHI for the purposes of marketing, subsidized treatment communication and for the sale of such information. YOUR RIGHTS REGARDING PHI You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer: • Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances or with documents released to us, to inspect and copy PHI that may be used to make decisions about service provided. • Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. • Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period. • Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for services, payment, or business operations. We are not required to agree to your request. • Right to Request Confidential Communication. You have the right to request that we communicate with you about PHI matters in a specific manner (e.g. telephone, email, postal mail, etc.) • Right to a Copy of this Notice. You have the right to a copy of this notice. WEBSITE PRIVACY Any personal information you provide us with via our website, including your e-mail address, will never be sold or rented to any third party without your express permission. If you provide us with any personal or contact information in order to receive anything from us, we may collect and store that personal data. We do not automatically collect your personal e-mail address simply because you visit our site. In some instances, we may partner with a third party to provide services such as newsletters, surveys to improve our services, health or company updates, and in such case, we may need to provide your contact information to said third parties. This information, however, will only be provided to these third-party partners specifically for these communications, and the third party will not use your information for any other reason. While we may track the volume of visitors on specific pages of our website and download information from specific pages, these numbers are only used in aggregate and without any personal information. This demographic information may be shared with our partners, but it is not linked to any personal information that can identify you or any visitor to our site. Our site may contain links to other outside websites. We cannot take responsibility for the privacy policies or practices of these sites and we encourage you to check the privacy practices of all internet sites you visit. While we make every effort to ensure that all the information provided on our website is correct and accurate, we make no warranty, express or implied, as to the accuracy, completeness or timeliness, of the information available on our site. We are not liable to anyone for any loss, claim or damages caused in whole or in part, by any of the information provided on our site. By using our website, you consent to the collection and use of personal information as detailed herein. Any changes to this Privacy Policy will be made public on this site so you will know what information we collect and how we use it. BREACHES: You will be notified immediately if we receive information that there has been a breach involving your PHI. COMPLAINTS: If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at Altitude Family and Internal Medicine. If you have questions and would like additional information, you may contact us at 303-730-2167.
  • Consent for Treatment

    Consent for Care I hereby consent to medical care for myself or as the guardian of the above named patient at Altitude Family & Internal Medicine. I authorize my medical provider to provide the treatment deemed necessary for the benefit the patient including but not limited to diagnostic testing, medications, and or other therapeutic modalities. Assignment of Benefits/Financial Agreement I hereby give lifetime authorization for payment of insurance benefits to be made directly to Altitude Family & Internal Medicine, and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default I agree to pay all costs of collections, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. Privacy Notice The Health Insurance Portability and Accountability Act (HIPAA) requires us to give you a notice of our privacy practices and to acknowledge your receipt of the notice. I have been provided the opportunity to receive a copy of the “Notice of Privacy Practices” that explains when, where, and why my confidential health information may be used or shared. I acknowledge that Altitude Family & Internal Medicine, the medical providers, and staff may use and share my confidential health information with others in order to treat me, to arrange payment of my bill, and for issues that concern Altitude’s operations and responsibilities. Policies/Procedures I have been provided an opportunity to read and receive a copy of Altitude Family & Internal Medicine’s policies and procedures. I agree to adhere to the policy and procedures of Altitude Family & Internal Medicine. I further agree that a photocopy or digital image of this agreement shall be as valid as the original.