• Instructions For Receiving Forms

    Please Read this information as our process has changed.

  • Please Note - At your annual Well Care visit you can request that your provider push a form to the My Health Connection Patient Portal. There is no charge for printing forms from your portal. 

    1. Payment is required prior to receiving your form.
    2. Regardless of the method you choose to request a form, pre payment will be collected prior to submission.
    3. If after reviewing your form request, we determine that payment is not necessary, you will be refunded.
    4. Please select your turn around time below.
    5. Add your credit card information
    6. Complete the Form Request Information including how you would like the form returned.
    7. Once our Medical Records Department has reviewed and completed your form, they will email you with the encrypted form attached.
    8. If you have elected to pick up your form, you will receive an email letting you know its ready for pick-up at our East Elizabeth Office.
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        7-10 Day Turnaround
        $10.00
          
        Next Business Day Turnaround
        $40.00
          
        Total
        $0.00

        Credit Card

      • Form Completion Instructions

        Please complete the information below indicating your contact information, relationship to patient, how you would like to receive your form and you preferred method of delivery.

      • Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders

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      • STEP 2 EMERGENCY CALLS

      • 3. Emergency contacts: Name/Relationship

      • DO NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS

        I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary, contact our health care provider. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices and release the school and personnel from any liability in compliance with their Board of Education policies
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      • Staff trained and delegated to administer emergency medications in this plan:

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      • Keep the child lying on their back. If the child vomits or has trouble breathing, place child on his/her side.

        If this conditions warrents meal accomodations from food service, please complete the form for dietary disabilitiy if required by

      • Adopted from the Allergy and Anaphylaxis Emergency Plan provided by the American Academy of Pediatrics, 2017

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