Doctor and Patient

Patient Forms

New Patient Packet (Required for Assisted or Independent Living patients only)

This packet includes new patient forms that must be completed and returned to our office. The packet includes "Patient Information", "Patient History", "Acknowledgement of Receipt of Notice of Privacy Practices", Authorization for the Use or Disclosure of Protected Health Information", and "HIPAA Authorization to Release Protected Health Information". 

Please include a copy of your insurance card and Driver's License with the completed forms.

Billing Statement and Disclosure

Please review Summit Medical Consultants' Billing Statement and Disclosure for important billing information.

Insurance

Summit Medical Consultants accepts all major insurances. The Network Participation List includes all insurance plans we accept.

Assisted Living Patient Phone Tree

The Assisted Living Patient Phone Tree includes the patient and family line phone number, as well as contact information for Summit Medical Consultants, the Practice Manager, and the Clinical Assistant Practice Manager.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

HIPAA Authorization to Release Protected Health Information (PHI) / Medical Records Request

To request a copy of your medical records or to release a copy of your medical records to a third party, complete the this form and mail or fax to Summit Medical Consultants.

Submit the completed form via mail or fax to:

Summit Medical Consultants

5023 W. 120th Avenue, #312

Broomfield, CO 80020

Fax: 720-523-1654