FORMS


 

NEW PATIENTS:  Please complete the new patient questionnaire(s) and email, mail or fax back to us before your visit at: admin@centerformultisystemdisease.com

or fax to 720-676-1703. 

The other forms are provided for your review only.  You will be asked to sign the other forms during your first visit and yearly thereafter.

RETURN PATIENTS:  No need to print any forms, but you will be asked to sign the forms at your first visit to Center for Multisystem Disease and yearly thereafter.

 

NEW PATIENT QUESTIONNAIRE

If you have both dysautonomia and APS, please complete the dysautonomia questionnaire first and then complete the questions of pages 3 and 4 of the APS questionnaire that you have not already answered on the POTS/dysautonomia questionnaire.

POTS        APS


OVERALL FUNCTIONAL ABILITY SCORE

Please refer to this form when you are completing the New Patient Questionnaire.

We will also provide this form to you to complete before office visits. 

Overall Functional Ability Score


MEDICAL RECORDS RELEASE

Please complete if you need to have your outside records sent to us.

Medical Records Release Form

 

HIPAA PRIVACY NOTICE

All patients must complete this form yearly.

HIPAA Privacy Notice

 

EMAIL AGREEMENT

Please complete yearly if you or your provider may want to communicate with our office by email.

Email Agreement Form

 

MEDICARE AGREEMENT

For patients with Medicare only.  All patients with Medicare must complete this form to yearly to receive care at Center for Multisystem Disease.

Medicare Agreement Form

 

PRACTICE POLICIES

All patients must sign this form yearly to receive care at the Center for Multisystem Disease.

Practice Policies