Mid-America Heart & Lung Surgeons


PATIENT INFORMATION SHEET

 
Patient Information
Sex

Marital Status

Race










 
Ethnicity


Spouse or Primary Insured Information
Emergency Contact
Insurance Information
Do you have healthcare insurance?

I also understand that I am financially responsible for all charges not covered by insurance.
I authorize my medical records from any healthcare facility be released to MidAmerica Heart and Lung Surgeons in order to assist in my care.
Signature of Patient or Authorized Person – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Mid-America Heart & Lung Surgeons


AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

 
I request and authorize the release of my healthcare information to the following individual(s) (other than my attending physicians):
This request and authorization applies to:


Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person (s) listed above. I understand that the person (s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Mid-America Heart & Lung Surgeons


REVIEW OF SYSTEMS

 

Retired?  

Marital Status
Check any that apply














– type  






Prior Operations

Add another Procedure?
Family History
Do you have a family history of:




Personal History
Tobacco Use - Smoking

Tobacco Use - Chew

Alcohol Use

Have you received both COVID-19 vaccinations?

Symptoms/Concerns
Do you have any of the following symptoms or concerns?
General




Skin


Head, Eyes, Ears, Nose, Throat





Respiratory/Breathing



Heart




Gastrointestinal






Urinary



Musculoskeletal




Neurological



Psychiatric


Endocrine


Hematology



Latex Allergy
Iodine/Contrast Allergy
Will you accept blood products for surgery if needed?
Medications

Add another Med?
Medication Allergies

Add another Allergy?
To the best of my knowledge the information provided above is correct and accurate:
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Mid-America Heart & Lung Surgeons


NOTICE OF PRIVACY PRACTICES

 
Would you like to read our Notice of Privacy Practices?    
Mid-America Heart & Lung Surgeons


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 
I hereby acknowledge that I have received a copy of Mid America Heart & Lung Surgeons, P.C.’s Notice of Privacy Practices
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Mid-America Heart & Lung Surgeons


IMPORTANT INSURANCE INFORMATION

 
Our practice participates with most insurance companies. If you have an HMO policy, it is your responsibility to have referral information with you. Physicians Assistants (PA’s) and Nurse Practitioners (NP’s) employed by Mid America Heart & Lung Surgeons will be helping with your surgical procedure and recovery. Separate charges will be submitted for their services. All charges are submitted to your insurance carrier for payment. However, the patient is responsible for Surgeon, PA and NP charges not paid by insurance. Your insurance might not cover these charges. Ultimately, it is the patient’s responsibility to contact their insurance carrier to determine the benefits their plan provides.

ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT. NECESSSARY FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE FEES NOT PAID BY INSURANCE. IT IS ALSO CUSTOMARY TO PAY COPAYS AND/OR DEDUCTIBLES AT TIME OF SERVICE UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE WITH OUR BILLING DEPARTMENT. FAILURE TO NOTIFY OUR OFFICE IN ADVANCE CONCERNING ANY CHANGE OR CANCELLATION IN YOUR INSURANCE COVERAGE WILL MAKE YOU FINANCIALLY RESPONSIBLE FOR ANY INCURRED CHARGES AFTER SUCH CHANGE GOES INTO EFFECT.
Patient or Authorized Person's Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Mid-America Heart & Lung Surgeons


MEDICARE PAYOR QUESTIONAIRE

 
Are you using Medicare or a Medicare Supplement insurance?    
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