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 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.

New Patient Information Forms

Please print this form SINGLE SIDED.

Download New Patient Form

Download Breast History 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

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 Breast Biopsy

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)
• Representative of the estate for deceased patients (Copy of the death certificate and documentation detailing Representative must be provided with 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:

If you have any questions please contact our office at