Patient Forms

If you have not received proper paperwork to fill out prior to an appointment, please download the documents below, complete them and bring them with you to your appointment.

 
 

  • Office New Patient Packet

    • English Version: Click here

    • Spanish Version: Click here

    • This PDF file includes the following documents:

      • Patient Information Sheet

      • Medication Allergy Sheet

      • Review of Systems

      • Authorization for Disclosure of Health Information

      • Financial Policy & Disclosure

  • Consent Letter: Click here

  • Procedure Packet

    • English Version: Click here

    • Spanish Version: Click here

    • This PDF file includes the following documents:

      • Patient Information Sheet

      • Medication Allergy Sheet

      • Review of Systems

      • Authorization for Disclosure of Health Information

      • Financial Policy & Disclosure

      • Consent Letter (download separately – PDF file)

      • FAQs

      • Advance Directive Policy

      • Plaza Anesthesia, P.C.

      • Patient Rights

      • Patient Responsibilities

Health Information Exchange

Mid-America Gastrointestinal Consultants PC., participates in various electronic health information exchanges designed to ensure my health information is available to all persons and entities providing me with care, payment for that care, or for other purposes permitted by law. This includes health information exchanges through Midwest Health Connection and Epic’s Care Everywhere.

The intent of these exchanges is to provide caregivers with secure access to patient health information so they can render the most effective care regardless of where the patient seeks that care. This access is automatic per regulatory guidelines. However, patients may choose to opt-out of this service by visiting the Midwest Health Connection website at www.mhc-hie.org and following the instructions to complete the Opt-Out form.