Forms

WELCOME! We look forward to having you as a patient, and would like to take this opportunity to thank you for choosing us to participate in your healthcare. Please complete and sign all appropriate forms and bring these with you for your first visit.

Your insurance company may require prior approval from your primary care provider for a consultation. If this is the case, you must obtain this prior to your appointment.

We accept cash, checks, debit cards, Visa and MasterCard. Please be prepared to pay your co-pay and coinsurance at the time of service. For further information on payment for medical services, see the “Credit Policy” form.

If you have any questions, please call our office and select option 2 (bone density test or office appointment) for assistance. Thank you for taking the time to read and complete this information prior to your appointment.

You have been given a check-in time 30 minutes before your appointment time to process the information you have provided. We greatly respect your time and make every effort to stay on schedule for all patients.

New Patients for Osteo Consults with Dr. Lewiecki

Additional information from other doctors will be necessary in order to evaluate your condition.
    Please bring with you or ask your physician to send us, the following:
         • All previous bone density tests (original printouts are preferred to copies)
         • Laboratory reports
         • Office and hospital medical records regarding any bone problems
         • X-rays, CT scans, and MRI reports
Please be advised, our office will contact you two days prior to your appointment to verify you have all requested information for your appointment. If you do not have all your information, your appointment may be rescheduled.

Please print, fill in, and bring the following to your appointment:

Osteo Consultation History Form for E. Michael Lewiecki, MD 
Receipt of Notice of Privacy Practices and Permission to Release Laboratory and X-Ray Results
Receipt of Financial Policy
Insurance Cards
Written order from referring doctor (As applicable)

For your records:

New Patients for Osteo Consults with Dr. Rudolph

Additional information from other doctors will be necessary in order to evaluate your condition.
    Please bring with you or ask your physician to send us, the following:
         • All previous bone density tests (original printouts are preferred to copies)
         • Laboratory reports
         • Office and hospital medical records regarding any bone problems
         • X-rays, CT scans, and MRI reports
Please be advised, our office will contact you two days prior to your appointment to verify you have all requested information for your appointment. If you do not have all your information, your appointment may be rescheduled.

Please print, fill in, and bring the following to your appointment:

Osteo Consultation History Form for Lance Rudolph, MD 
Receipt of Notice of Privacy Practices and Permission to Release Laboratory and X-Ray Results
Receipt of Financial Policy
Insurance Cards
Written order from referring doctor (As applicable)

For your records:

New Patients for Internal Medicine with J. Chavez, CNP

Please print, fill in, and bring the following to your appointment:

History Form for Julia Chavez, CNP 
Receipt of Notice of Privacy Practices and Permission to Release Laboratory and X-Ray Results
Receipt of Financial Policy
Insurance Cards
Prior Records (This is helpful, but not required)

For your records:

E. Michael Lewiecki, MD                                    
Lance A. Rudolph, MD

This page update 1/21/13