300 Oak Street NE
Albuquerque, NM 87106

CLINICAL RESEARCH & OSTEOPOROSIS CENTER

Phone: 505-855-5525
Fax: 505-884-4006
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-------------------E. Michael Lewiecki, MD, FACP, FACE - Osteoporosis Director -|- Lance A. Rudolph, MD - Research Director
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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.





Forms for
New Patients
for
Osteo Consults
with
Dr. Lewiecki

Forms for
New Patients
for
Osteo Consults
with
Dr. Rudolph

Forms for
New Patients
for
Internal Medicine
with
Julia Chavez, CNP










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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.



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)

Notice of Privacy Practices
Notice of Financial Policy













.




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.



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)

Notice of Privacy Practices
Notice of Financial Policy


















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)

Notice of Privacy Practices
Notice of Financial Policy

 




















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

This page update 10/31/13

 


 
 

Mike's Manual
 Mike's Manual


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