Contact us via telephone, email or the form below. We look forward to helping you with your health questions and goals. We will contact you to schedule an appointment.
Or call 303-898-1552
By submitting this form, you are agreeing to and acknowledging the following:
- You are electing to receive consulting services from Dr. Robert Maulitz, a physician affiliated with Second Opinion Resource, PLLC.
- You understand these services may be rendered by Dr. Maulitz, either in person or via Zoom or a similar platform, as you and Dr. Maulitz mutually agree.
- You understand that Dr. Maulitz will not conduct a physical examination, but will review the medical records and other documentation you provide and then will discuss your medical history and treatment options with you.
- You understand that Dr. Maulitz (i) does not maintain a traditional medical practice, (ii) does not render consulting services other than by appointment (iii) is not available “on-call” and (iv) will not serve as your treating physician. If you experience a medical emergency, you should contact 911 or proceed to the nearest emergency room for treatment.
- Neither Second Opinion Resource, PLLC or Dr. Maulitz guarantees you will achieve any particular outcome associated with your selected course of treatment and the consulting services you receive from Dr. Maulitz.
- You understand that Dr. Maulitz and Second Opinion Resource, PLLC are not participating providers with and do not bill insurance companies for the services rendered by Dr. Maulitz.
- You understand that you will be expected to make payment prior to or at the time services are rendered. While Second Opinion Resource, PLLC will provide you with a receipt, it is unlikely that the services provided will be reimbursable by your insurance company.
- You understand that Second Opinion Resource, PLLC will maintain your medical and financial information in confidence in accordance with Colorado law.
- You or your personal representative have the right to have access to your medical record maintained by Second Opinion Resource, PLLC upon submission of a valid authorization for inspection of records which shall be dated and signed by you. Inspection shall be at a reasonable time and upon reasonable advance notice.
- You or your personal representative have the right to obtain a copy of your medical record maintained by Second Opinion Resource, PLLC upon submission of a signed and dated written request. You understand there may be a fee associated with requesting a copy of your medical record.
- By signing below, if you receive service via Zoom or a similar communications platform, you are representing that you are physically present in the State of Colorado at the time you receive services.
- If you have insurance coverage through Medicare, a Medicare Advantage Plan or a Medicaid program, you understand that the services you are electing to receive are not covered services and that Medicare and Medicaid will not pay or reimburse for these services.
- You acknowledge you have had an opportunity to review this Agreement and ask any questions.