Please fax any change in insurance using the Patient Registration form to 303-426-9581 prior to your next appointment.

Questions?

Call the Mountainland Pediatrics Billing Office for help on any form. 303-853-3440.

Forms & Policies

The following forms and policies are provided for your information and convenience. You may download and print any of our forms listed below before coming to our office. This will get you out of the waiting room and in to see the doctor a lot quicker! You may either bring them with you to the first visit, or if you wish, fax them to us at 303-426-9581 before your appointment.

Some documents require Adobe Reader. Click to download.

Expectant Parents and Parents Seeking a New Pediatrician

Meet the Doctor Questionnaire
Please bring when interviewing our Practice to be your child's healthcare provider

Expectant Parent/Newborn Questionnaire
Please fax in advance of your baby's first newborn appointment at Mountainland Pediatrics.

New Patient Registration Packet

Contact Information and Acknowledgement of Receipt of Policies
Please read the Privacy Rights and Financial Policies available in the last section of this web page before signing this document.

Patient Medical History

Authorization for Child's Treatment
(Permission for an adult other than parent or guardian to seek treatment for a child. This is only required if a non-guardian adult will be bringing your child to an appointment.)

Patient Registration Form

Existing Patients

Change of Responsible Person and/or Insurance
Please complete a new Patient Registration Form

Change of Patient Contact Information
Please call changes into your Mountainland Pediatrics office or the Billing Office at 303-853-3440.

MCHAT Questionnaire
The Modified Checklist for Autism in Toddlers (M-CHAT) assesses risk for Autism in children between the ages of 15 and 30 months and is usually done during a well-child visit. Please read the additional explanation document below for more information.

M-CHAT Explanation
The Modified Checklist for Autism in Toddlers (M-CHAT) assesses risk for Autism in children between the ages of 15 and 30 months and is usually done during a well-child visit. This document is the explanation. The questionnaire is above.

Mountainland Pediatrics Record Release
to have your child's records sent to another person

Policies

Mountainland Pediatrics Office and Financial Policies 2010

Mountainland Pediatrics Privacy Rights