ESTABLISHED PATIENT INFORMATION SHEET

Patient Information

Patient Name - Last *

First *

Sex *
Male Female

Visit Date *

Address *

City *

State *

Zip *

Home Phone *

Alternate/Cell Phone

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Email Address *

Marital Status *
S M W D

Social Security No. *

Birthdate *

Age

Please attach a scan or photo of the front of your driver’s license

Pharmacy Name

Pharmacy Phone

Pharmacy Address

City

State

Zip

Language Spoken

Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Declined

Primary Insured Information

Is patient the primary insured?
Yes No

Name - Last *

First *

Birthdate *

Social Security No. *

Employer *

Employer Phone

Phone number if different from yours

Physician who sent you to us *

Phone

Address

City

State

Zip

Family Physician (if different from referring physician above)

Phone

Address

City

State

Zip

Emergency Contact

Name *

Relationship *

Phone *

Insurance Information

Do you have healthcare insurance? *
Yes
No

Our practice participates with most insurance companies. If you have an HMO policy, it is your responsibility to have referral information with you. Physician assistants (PA’s) and nurse practitioners (NP’s) employed by MidAmerica Heart and 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. NECESSARY FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE CARRIER PAYMENTS. HOWEVER, THE PATIENT IS RESPONSIBLE FOR ALL 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 WTH 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.

Are you using a Medicare Advantage plan? *
Yes
No

Primary Insurance *

Policy No. *

Group No. *

Claims Mailing Address *

City *

State *

Zip *

Name of Policy Holder *

Relationship *

Birthdate *

Social Security No. *

Please attach a scan or photo of the front of your insurance card

Please attach a scan or photo of the back of your insurance card

Do you have secondary healthcare insurance? *
Yes
No

MEDICARE, MEDICAID, AND COMMERCIAL LIFETIME ONE CONSENT AGREEMENT: I request that payment under the medical insurance program be made to MidAmerica Heart and Lung Surgeons on any service furnished me by these physicians. I further authorize the release of necessary medical records information to any carrier listed on the claim for the purposes of processing any Medicare, Medicaid or Commercial insurance claim. I also authorize the release of my medical records to any insurance company requesting this information regarding my medical status for the purposes of applying for health or life insurance, or in the event that this information would be needed to process my claim for medical or disability benefits.

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.

Date *

REVIEW OF SYSTEMS

What problem brings you to see us today? *

Personal History

Tobacco Use - Smoking *
Yes
No

Tobacco Use - Chew *
Yes
No

Alcohol Use *
Yes
No

Have you received both COVID-19 vaccinations? *
Yes
No

Medications

Are you taking any medications? *
Yes No

Medication Allergies

Do you have any medication allergies? *
Yes No

Prior Operations

Have you had any prior operations? *
Yes No

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

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.

Date *

NOTICE OF PRIVACY PRACTICES

Would you like to read our Notice of Privacy Practices? * Yes No

MIDAMERICA HEART & LUNG SURGEONS - 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
If you have any questions about this notice, please contact:
Privacy Officer - MidAmerica Heart & Lung Surgeon.
4320 Wornall Road, Suite 50 - Kansas City, MO 64111
Phone: (816) 931-3312 Fax: (816) 531-9862

OUR PLEDGE REGARDING MEDICAL INFORMATION:

We understand that medical information about you and your health is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our organization, whether made by our employees or your physician. The law requires us to: Make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms of the notice that is currently in effect.

WHO WILL FOLLOW THIS NOTICE:

This notice describes our organization’s practices and that of:

Any health care professional authorized to enter information into your medical record.
All departments and entities within our organization.
All employees and employed physicians.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:

The following are examples of the types of uses and disclosures of your protected health information that your organization is permitted to make once you have acknowledged receipt of our Notice of Privacy Practices.

For treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other employees who are involved in taking care of you.
For payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company, or a third-party payer. Unless a restriction is requested, the guarantor/responsible party will have access to information created during the episode of treatment.
For healthcare operations: We may use and disclose medical information about you for healthcare operations. These uses and disclosures include the following: Quality assessment and improvement activities, reviewing competence or qualifications of healthcare professionals, reviews by external agencies for licensure, accreditation, or auditing.
For other benefits and services: We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other activities, such as to send you a newsletter about our practice and the services we offer.

OTHER PERMITTED OR REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITH YOUR CONSENT, AUTHORIZATION, OR OPPORTUNITY TO OBJECT

We may use and disclose your protected health information in the following instances:

Individuals involved in your healthcare: We will only disclose to a member of your family, a relative, a close friend, or any other person that you identify, your protected health information that directly relates to that person’s involvement in your health care. You will be asked to provide the names of these individuals. Any individuals you identify that will be receiving information about you over the phone must provide your date of birth and social security number. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
Disaster relief: Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Emergencies: We may use or disclose your protected health information in an emergency situation. If this happens, we shall try to obtain your acknowledgement as soon as reasonably practicable after the delivery of treatment.
Communication barriers: We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so due to substantial communication barrier and it is determined, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
Appointment reminders/scheduling and follow-up calls: We may use and disclose health information to contact you as a reminder that you have an appointment, have been referred to schedule a visit, or to follow-up with you on a recent visit. We may leave a brief reminder on your answering machine/voicemail system unless you tell us not to.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION, OR OPPORTUNITY TO OBJECT

We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Required by law: When required to do so by federal, state, or local law, including those that require the reporting of certain types of wounds or physical injuries.
Public health: For public health activities and purposes of controlling disease, injury, disability, reporting births and deaths, and reporting any type of abuse, neglect, or domestic violence. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Health oversight: To a health oversight agency for activities authorized by law, such as audits, investigations, and inspections that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
Food and Drug Administration: To a person or company required by the Food and Drug Administration to report adverse events, product defects, or problems, biologic product deviations, track products, to enable product recalls, to make repairs or replacements, or to conduct post market surveillance, as required.
Legal proceedings: In the course of any judicial or administrative proceedings, in response to a court order or an administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request, or other lawful purposes.
Law enforcement: Law enforcement purposes include: Identification or location of a suspect, reporting details of a suspicious death, or other legal processes required by law.
Coroners, funeral directors, or organ donation: To a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. Protected health information may be used and disclosed for cadaveric organs, eye, or tissue purposes.
Criminal activity: Consistent with applicable federal and state laws, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
Military activity and national security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military command authorization for the purpose of a determination by the Department of Veteran’s Affairs of your eligibility for benefits, to foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities including for the provision of protective services to the President or others legally authorized.
Worker’s compensation: As authorized to comply with the worker’s compensation laws and other similar legally established programs.
Inmates: If you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
Change of ownership: In the event that Mid America Heart & Lung Surgeons, P.C. is sold or merged with another organization, your protected health information will become the property of the new owner.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

In addition to your rights as patient, we also ask that you respect the rights of other patients by not discussing any information you may see or hear while receiving treatment in our facility. You have the following rights regarding medical information we maintain about you:

Right to inspect and copy: You may inspect and obtain a copy of your protected health information that is obtained in a designated record set for as long as we maintain the protected health information. A designated record set contains medical and billing records and any other records our organization uses for making decisions about you. Your request must be submitted in writing. A copy of the authorization to request release of information is available from the Privacy Officer. If you request a copy of the information, we may charge a reasonable free for the costs of copying, mailing, or other supplies associated with your request.

We may deny your request to inspect and copy based on the federal laws above. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the organization will review your request and the denial. The person conducting the review will not be the person who denied your original request. We will comply with the outcome of the review.

Right to amend: This means that if you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by our organization. Your request must be made in writing and submitted to the Privacy Officer within the entity. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the medical information kept by our organization;
Is not part of the information which you would be permitted to inspect and copy (see above); or
Is accurate and complete

Right to an accounting of disclosures: This means that you have the right to request an “accounting of disclosures”. This is a list of the disclosures we make of medication information about you for purposes other than treatment, payment of health care operations as described in this Notice of Privacy Practices. It will also exclude disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes.

To request this list of accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period, which may not be longer than five years. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to request restrictions: This means that you have the right to request a restriction of limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. (MID-AMERICA HEART & LUNG SURGEONS, P.C. IS NOT LEGALLY REQUIRED TO AGREE WITH YOU REQUEST) If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your re1quest in writing to our Privacy Officer. In you request you must tell us:

What information you want to limit;
Whether you want to limit our use, disclosure, or both; and
To whom you want the limits to apply (for example, disclosure to your spouse).

Right to request confidential communications: This means that you have the right to request that we communicate with you about medical matters in a certain way or at a certain location. (For example, you can ask that we only contact you at work or be mail.) To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a paper copy of this notice: This means that you have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

CHANGES TO THIS NOTICE: We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in each notice.

COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services at:

The U.S. Department of Health and Human Services
200 Independence Avenue S.W.
Washington, D.C. 20201
1-877-696-6775

To file a complaint with the organization, contact our Privacy Officer. All complaints must be submitted in writing.

OTHER USES OF MEDICAL INFORMATION:

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosure we have already made with your permission, and that we are required to retain our records of the care that we provide to you. Please contact our Privacy Officer to revoke your authorization.

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

Date *

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