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.

 

Expectant Parents and Parents Seeking a New Pediatrician

Whether you are expecting your first child or shopping for a new pediatrician for your children, finding the right pediatrician for your family is a very important undertaking. We welcome the opportunity to meet with you anytime to show you around our offices and answer any questions you may have. Please call 303-430-0823 Monday through Friday, 8:00 am to 5:00 pm to schedule a consultation appointment.

 

Telehealth Consent Forms

Please complete and return these forms to MLPMedRecords@mlpi.org or fax the forms to 303-426-9581 to consent to video-based web appointments during the COVID-19 Pandemic.

English

Spanish

 

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

M-CHAT 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 an explanation. The questionnaire is above.

 

Release of Information

A valid Release of Information (ROI) must be submitted in order to authorize the release of medical records.  Please complete the form below and submit to Mountainland Pediatrics’ Medical Records Department by:

Email: MLPMedRecords@mlpi.org

Fax: 303-426-9581

In person: At our Mountainland Pediatric front desk

Mountainland Pediatrics Record Release – English

Mountainland Pediatrics Record Release- Spanish

 

Insurance

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

 

Policies

Mountainland Pediatrics Office and Financial Policies 2010

Mountainland Pediatrics Privacy Rights