Forms

Instructions:
Please fill out a Patient Intake Form using one of the two methods below:

Click Here to Manually PRINT PDF then fill out form then scan it or fax it or email it or bring it to our office.

OR...

Fill out the ONLINE PATIENT INTAKE FORMS on this page (all 3 of them) and when completed click the "Submit" button for each of the 3 forms. Please provide Patient Intake Form prior to setting your appointment. Thank you!

Richard Y. Harris, M.D.
381 Rampart Range Road

Woodland Park, Colorado, 80863
Email: [email protected]
Fax: 719.687.0940

Call 719-687-6088 if you have any questions.

SSN

Periods irregular?

Yes

Assignments & Authorizations

* = Required Field

Mother

Check any of the following symptoms you’ve had in the last 2 weeks - Breast:

lump

tenderness

nipple discharge

Policy Holders Date of Birth

Street Address

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Richard Y. Harris, MD to release any medical or incidental information that may be necessary for either medical care, or in processing applications for financial benefit. *

Checking this box stipulates that I agree

Phone *

Sibling 3

State

Check any of the following symptoms you’ve had in the last 2 weeks - Endocrine:

urinating a lot

drinking a lot

poor wound healing

temperature intolerance

hot flashes

Father

Clients Date of Birth *

Clients Name *

Child 3

Email: *

Check here to receive email updates

ID Number

Date of Birth *

Today's Date *

Phone *

Richard Y. Harris, MD

Occupation

Clients Name: *

Herbs

Relationship to Patient

Insurance Company

HIPAA - Privacy Policy Patient Consent Form *

Group Number

Child 1

Patient’s Relationship to Policy Holder

Self

Spouse

Child

If checked how many drinks per day

Please list your prescription and dosages of medications you take

Number of children born alive

Postal Code

Employer

Menstrual History

Spouse

Sibling 2

Lifestyle Choices - Exercise:

Client's Medical/Family History

* = Required Field

Today's Date *

Policy Holder

Today's Date *

Child 2

Patient Name: *

How many pregnancies?

Sibling 1

Tell us about immediate family members

Check here if adopted

Birth Place

If menopausal:

Clients Date of Birth *

Specialists You Are Seeing

City

Check any of the following symptoms you’ve had in the last 2 weeks - Blood/Lymph:

bleeding

easy bruising

swollen lymph nodes

Smoking (if yes)

Caffeine:

Cola

Coffee

Tea

Pharmacy Preference

Medical History/Surgeries:

I understand that I have certain rights to privacy regarding my protected Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out:  Treatment (including direct or indirect treatment by other healthcare providers involved in my Treatment).  Obtaining payment from third party payers (I.E, my insurance company).  The day to day healthcare operation of your practice. I have also been informed of and given the right to review and source a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. *

Checking this box stipulates that I agree

Parent/Guardian Name:

Clients Name *

Date of last Physical

Policy Holder's SSN

MEDICARE/MEDICAID: I certify that the information given by me in applying for payment is correct and authorize release of all records on request. I request payment of authorized benefits be made on my behalf. *

Checking this box stipulates that I agree

Check any of the following symptoms you’ve had in the last 2 weeks - Allergic:

anaphylaxis

hay fever

hives

Allergies

Education/Degree

Home Phone *

Client Information

* = Required Field

Check any of the following symptoms you’ve had in the last 2 weeks - Cardiovascular:

chest pain or pressure

swelling in feet

calf pain with walking

irregular heart beats

palpitations

fainting

lightheadedness

Woodland Park Medical Clinic

Lifestyle Choices - Alcohol

Physician that conducted Physical

Vitamins

Emergency Contact/s *