Mid-America Heart & Lung Surgeons


NEW PATIENT INFORMATION SHEET

 
Patient Information
Sex *

Marital Status *

Retired?  

Race










 
Ethnicity


Primary Insured Information
Is patient the primary insured?
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

 
Release  *

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

 
Check any that apply *














– type  





     
     
Prior Operations
Have you had any prior operations? *
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
Are you taking any medications? *
Medication Allergies
Do you have any medication allergies? *
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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