1960 Ogden St. Suite 120, Denver, CO 80218,

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1 Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible service. In order to be efficient and provide you with the best care, we ask you to review the following procedures and policies for our office. Hours: Our phones are open from 7a.m. to 5p.m., Monday through Friday. Each provider s schedule is set each week with specific days off. Please request information regarding your PCP. No show appointments: It is essential for your health and the management of the clinic that appointments are kept. If you miss two or more appointments without calling, we may ask you to seek care at another clinic. We ask that you call 24 hours in advance to change or cancel your appointment. **If you call to cancel within 4 hours of your appointment, we will consider it a no show. Appointments: You should receive a telephone reminder/confirmation call two days prior to your appointment. Please arrive 30 minutes before your scheduled appointment. This allows us time to update your account and facilitate proper billing to your insurance without delaying your visit. As we strive to respect our patients scheduled appointment times, if you are more than 10 minutes late your appointment may need to be rescheduled. As required by your insurance company, we will request presentation of your insurance card and co-payment at the time of service. If there is a balance on your account you will be expected to pay this at your appointment. New Patients: If you do not show for your first appointment, we will no longer see you as a patient. Cancellations: As a courtesy to other patients, we request that you notify us as soon as possible if you need to cancel or reschedule your appointment: this allows us the opportunity to offer the appointment time to other patients. Cancellations with less than 4 hours notice will be considered a no show appointment. Deductibles/Co-ins and Co-payments: Any insurance or contract that informs our office of deductibles/co-ins and copayments will be requested at check in. You will be asked for payment toward annual deductible, any co-insurance due and applicable co-payment before being called back for your appointment. If you have a special circumstance and are not able to make your co-payment the day of your appointment, you may be asked to reschedule unless previous arrangements have been made with the clinic manager. Behavior: Our patients are very important to us and we promise to treat all patients with dignity and respect as well as make the clinic environment welcoming and pleasant. As such, we expect the same behavior to be followed by all of our patients. If one of our healthcare team members has not met this expectation, please request to speak with management immediately. Please note, if you are found not to be meeting this expectation we reserve the right to refuse care for you and your family, and you or your family may be asked to seek care elsewhere. Please know this is a zero tolerance policy in our clinic. Prescription refills: Please call your pharmacy with your refill requests (even if you have no refills left). It may take as long as 24 to 48 hours for a refill request to be processed. Please do not wait until you are out of you medication before calling in your request. Narcotic refills will only be filled Monday through Thursday, and Friday before 12 p.m. Thank you for choosing Denver Medical Associates for your healthcare needs.

2 Today s Date: Denver Medical Associates Health Screening Template Please answer these questions to help us maintain accurate records and provide high quality care. All information will be kept confidential. Please discuss any questions about these items with your doctor or clinical staff. Patient Name: DOB: Age: Sex:! Male! Female Reason for Today s Visit: 1) 2) Preferred Pharmacy Name: Location: Number: Allergies Allergic To Reaction Allergic To Reaction Medications Please list all your MEDICATIONS (prescriptions, over the counter, vitamins, herbal supplements). Include the dose and frequency (daily, twice per day, etc ) for each. Drug Name Dosage Frequency Drug Name Dosage Frequency Past Surgical History Please list all OPERATIONS you have had and give the approximate DATE of each: Operation Date Operation Date! Appendectomy! Joint Surgery! Cholecystectomy (gallbladder out)!! Hysterectomy!! Heart Surgery! Medical Problems (Previous or Current Conditions) Please check ALL that apply Headache! Eye Disease! Allergies! High Blood Pressure! Heart Attack! Circulatory Problems! Atrial Fibrillation! Other Heart Problems! Asthma! Emphysema/COPD! Tuberculosis! Heartburn/GERD! Stomach Ulcer! Liver Disease! Colon or Bowel Problems! Gall Bladder Disease! Urinary Tract Infections! Kidney Stones! Kidney Disease! Back Pain! Joint Problems! Gout! Diabetes! Thyroid Disease! Seizures! Stroke/TIA! Neuropathy! Other Neurological Dz! HIV! Hepatitis C! Sexually Transmitted Dz! Skin Disease! Anemia! Blood Clots in leg or lung! Cancer! Depression! Anxiety! Insomnia! Other Mental Health Problem! Substance Abuse! Please fill out both sides of this form

3 Denver Medical Associates Health Screening Template Family History Mother Father Siblings Maternal GM Maternal GF Paternal GM Paternal GF High BP / Heart Disease Lung Disease Bowel Disease Diabetes Neurological Disease Cancer (Type) Depression OR Mental Health Substance Abuse Other Social / Occupational History Marital Status:!S!M!D!W Hobbies / Recreation: Present Occupation? Highest Level of Education Who lives with you? Do you feel safe at home?! Yes! No Do you prefer to receive information through (please check all that apply):! Written material! Visual aids! Discussion! Other Do you drink alcohol (beer, wine, spirits)?! Yes! No How often? How many drinks at a time? Do you use recreational drugs?! Yes! No Type Frequency Do you smoke Cigarettes or use tobacco products?! Yes! No Type: Amount per day: Do you have exposure to second hand smoke?! Yes! No How often do you exercise: What type of exercise? Do you have a living will or advanced directive for healthcare?! Yes! No Preventative Health Influenza / Flu Tetanus Vaccine Pneumonia Vaccine Hepatitis B Vaccine Shingles Vaccine Colonoscopy Bone Density Dental Exam Eye Exam WOMEN ONLY: Last Pap Smear Are you Sexually active:! Yes! No Mammogram Do you prefer to have sex with:! men! women! both MEN ONLY: Prostate Cancer Screening Are you Sexually active:! Yes! No Do you prefer to have sex with:! men! women! both Patient Health Questionnaire (PHQ- 2) (Please circle your response) Over the past 2 weeks, how often have you been bothered by any of the following problems? Not at All Several Days More Than Half the Days Nearly Every Day 1) Little interest or pleasure in doing things ) Feeling down, depressed or hopeless Please fill out both sides of this form

4 Print Print Clear Clear Medical Record # Medical Record # Patient Patient Information Information Full Name Full Name Date Date of Birth of Birth Maiden Maiden or Other or Other Names Names Used Used Social Social Security Security Number: Number: XXX-XX- (last 4 (last digits) 4 digits) Day Phone Day Phone # Cell # Cell # City City State State Zip Zip Release Release From From Care Care Site Name Site Name Phone Phone # # Fax # Fax # City City State State Zip Zip Release Release To To Person/Company/Organization Name Name City Phone Phone # # Fax # Fax # City State State Zip Zip Purpose Purpose Date(s) Date(s) Of Information Of Information To Be To Released Be Released Continuation Continuation of Care of Care Insurance/WC Legal Legal Date(s) Date(s) of Service of Service from from through through Personal Personal Other Other (specify): (specify): Date(s) Date(s) of Service of Service from from through through Information Information To Be To Be Released/Accessed I would I would like copies like copies of the of items the items checked checked below below for the for treatment the treatment dates dates listed listed above. above. Emergency Emergency Report Report Discharge Discharge Summary Summary History History & Physical & Physical Imaging Imaging CD/Film CD/Film Operative Operative Report Report Consultation Consultation Laboratory Laboratory Imaging Imaging Report Report Clinic Clinic Visit Visit Billing Billing Records Records Cardiac Cardiac Studies/EKG Studies/EKG Other: Other: Disclosure/Access Format Format I would I would like copies like copies of the of items the items checked checked above above in the in following the following format: format: Paper Paper format format US Mail US Mail CD CD Fax (healthcare Fax (healthcare provider provider only) only) Paper Paper format format pick up pick up Review Review only only to: to: Patient Patient Access Access Information Information I will provide I will provide a picture a picture ID prior ID to prior accessing to accessing my medical my medical record. record. I may I review may review my medical my medical record record without without a charge. a charge. If I request If I request copies copies of my of medical my medical record, record, I may I be may charged be charged a fee. a fee. I will refer I will my refer questions my questions regarding regarding treatment, treatment, prognosis, prognosis, or other or other clinical clinical matters matters to my to physician. my physician. A Care A Care Site professional Site professional will supervise will supervise the review the review of my of medical my medical record. record. If I am If involved I am involved a research in a research study study involving involving medical medical treatment, treatment, my access my access to the to research the research study study content content may be may temporarily be temporarily suspended suspended for as for long as as long the as research the research is in progress. is in progress. At the At completion the completion of the of research, the research, access access to my to medical my medical record record will be will be reinstated. reinstated. I Understand I Understand That That The information The information to be to released be released may include may include a diagnosis a diagnosis or reference or reference to the to following the following condition(s): condition(s): behavioral behavioral health health services/psychiatric care; care; sickle sickle cell anemia; cell anemia; genetic genetic testing; testing; acquired acquired immune immune deficiency deficiency syndrome syndrome (AIDS) (AIDS) or human or human immunodeficiency virus virus (HIV); (HIV); or drug or and/or drug and/or alcohol alcohol abuse. abuse. Without Without my express my express revocation, revocation, this authorization this authorization will automatically will automatically expire expire 180 days 180 days from the from date the signed date signed below, below, unless unless I request I request an expiration an expiration date less date than less 180 than days. 180 days. I may I revoke may revoke this authorization this authorization in writing in writing at any at time, any time, except except to the to extent the extent that action that action has already has already been been taken taken to comply to comply with it. with it. Information Information disclosed disclosed pursuant pursuant to the to authorization the authorization may be may subject be subject to redisclosure to redisclosure by the by recipient the recipient and is and no is longer no longer protected protected by the by HIPAA the HIPAA Privacy Privacy rule. rule. My signature My signature is required is required to validate to validate this authorization. this authorization. If I do If not I do sign not this sign authorization, this authorization, this Care this Care Site will Site still will provide still provide treatment treatment and and seek seek payment payment for services for services provided. provided. According According to State to State Statutes, Statutes, this care this site care may site charge may charge for copies for copies of medical of medical records. records. Signature Signature of of Patient/Guardian/Personal Representative Relationship Relationship (if not (if patient) not patient) Date Date Personal Personal Representative s PRINTED PRINTED Name, Name, Address, Address, and Phone and Phone Number Number If patient If patient is unable is unable to sign, to sign, document document reason: reason: For Office For Office Use Use Only Only Date Date Authorization Authorization Received: Received: By: By: Identification/Driver's License License # Verified: # Verified: Date Date Request Request Completed: By: By: Delivery Delivery Instructions: Instructions: PATIENT PATIENT INFORMATION Authorization for for Release/Disclosure of Protected of Protected Health Health Information (PHI) (PHI) Place Place label label here. here. Scanning Scanning does does NOT NOT work work if label if label is is outside outside this guide. this guide. EH-FR-MR SCLHS

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