top of page

Contact/Intake Forms

If you need more information, have questions, or would like to offer a suggestion, please be in touch. You can contact me via phone, email or by filling out the form.

​

I’ll get back to you as soon as possible. 

Tel: 970-259-1712                

fax: 970-259-2466

www.peakwell.com

mikel@peakwell.com

Office address:

2257 Main Ave

Durango, CO 81301

​

Mailing Address:

P.O. Box 2207

Durango, CO 81302

​

​

Client Forms- to download and Print

Client Registration Form

Payment Policy

HIPPA 

Compliance form

form anchor
Questions?

Success! Message received.

Client Forms- to fill out online if emailed forms are not able to be opened

Before filling out forms please call to schedule appointment 

​

Please only fill out these forms if the forms that were emailed to you are unable to be opened.  

Peak Wellness and Nutrition Inc. 

Client Information

Once you have scheduled your consult please fill out intake form at least 24 hours prior to your appointment.

Payment Policy

Beginning February 1, 2022 unless prior arrangements have been made, payment is due at the time of service. Peak Wellness and Nutrition is able to bill Anthem Blue Cross Blue Shield (Video conferences are not a covered service).  Peak Wellness & Nutrition is not able to bill other insurance companies but will issue a superbill to the client that the client can submit to the insurance company for reimbursement. Peak Wellness & Nutrition accepts payments in the form of cash, checks, and credit card (Master Card and VISA).  All video consults must be paid for prior to the consult.

 

Charges for services effective 2/1/22:

 

Initial Consultation 60 minutes:   $130.00* 

Follow-up Consultation, 60 minutes: $120.00*

 * $40 discount offered to those who pay day of service

 

Additional discounts available:

  • Initial 1 hour consult + 1 hour follow up appointment- $160**​

  • 4 one hour follow up appointments (may be divided into 1/2 hr appts) - $270**​

  • 10 one hour follow up appointments (may be divided into 1/2 hr appts)- $550​**

  • Please inquire of rates for other services.

** Payment must be paid in full at appointment to obtain discount.  Payment is non-refundable and credit expires 1 year from date of purchase.

​

Payments can be made via cash, check or credit card.​​

​

Video Consult Policy: Video consult payment is due 24 hours prior to consult.  If payment arrangements have not been made the appointment will be cancelled.

 

Cancellation Policy: If you must cancel an appointment, please notify the office at least 24 hours prior to the scheduled appointment. You will be charged for a full hour of time if you fail to show up for your appointment without proper notification.

Provider Notice of Privacy Practices

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

 

Uses and disclosures of health information:

We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.  Continuity of care is part of treatment and your records may be shared with other providers to you are referred.  Information may be shared by paper mail, electronic mail, fax and other methods. 

 

We may use or disclose identifiable health information about you with without your authorization for several reasons.  Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies.  We provide information when otherwise required by law, such as for law enforcement in specific circumstances.  In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you.  If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future use and disclosures.

 

We may change our policies at any time.  Before we make significant change in our policies, we will change our notice and post the new notice in the waiting area.  You can also request a copy of our notice at any time.  For more information about our privacy practices, contact the person listed below. 

 

Individual rights:

In most cases, you have the right to look at or get a copy of health information about you that we use to make decisions about you.  If you request copies, we will charge you only normal photocopy fees.  You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment, or related administrative purposes and other than when you explicitly authorized it.  IF you believe that information in your record is incorrect or if important information is missing, you have the right to that we correct the existing information or add the missing information.

 

Complaints:

If you are concerned that we have violated your privacy rights, or if you disagree with a decision we made about access to your records, you may contact the person below.  You may also send a written complaint to the U.S. Department of Health and Human Services.  The person listed below can provide you with the address upon request. 

 

Our legal duty:

We are required by law to protect the privacy of your information, provide this notice about our information practices, follow the information practices that are described in this notice and obtain your acknowledgement of receipt of this notice. 

If you have any questions or complaints please contact:

Peak Wellness and Nutrition Inc. P.O. Box 2207, Durango, CO 81302

(970) 259-1712

bottom of page