New Patient Packet

  • McPherson Medical and Surgical Associates New Patient Packet

    1000 Hospital Dr, McPherson, Kansas 67460 Building 3 620-241-7400

  • Please complete this packet to the best of your ability. Once we receive it, we’ll upload it to your chart and share it with your new Primary Care Provider for review.

    To keep your appointment on schedule, please plan to complete this packet at least 48–72 hours (about 3 days) before your visit. If it’s not completed in time, we may need to contact you to reschedule.

    Thank you,
    Your Patient Navigator Team — Savannah, Maci, Casi, & Leah

  • Below is a listing of our providers currently accepting new patients. If you have a preference on the provider, please denote that or simply highlight “no preference” and we will take care of the rest. We work hard to connect you with a provider that will meet your individual needs but cannot guarantee a specific provider’s availability.*

  • You will receive follow-up communication from our office regarding your request as soon as possible. This does not obligate you to stay with this provider. 

     

    FOR OFFICE USE ONLY 
    Date Recieved: 

    Date Patient Contacted: 

    Date of Appointment: 

  • Patient Information and Demographics

  • Patient Birth Sex*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Marital Status*
  • Do you have insurance?*
  • Format: (000) 000-0000.
  • Do you have secondary insurance?*
  • Format: (000) 000-0000.

  • I hereby authorize the release of medical information to insurance carriers concerning my illness and treatment. I hereby assign payments for all medical services rendered to McPherson Medical and Surgical Associates. I acknowledge that I am responsible for payment for all charges incurred that may not be covered due to a required co-payment, insurance deductible or classified by my insurance as non-covered services. I hereby acknowledge that I also have received a copy of the McPherson Medical and Surgical Associates Notice of Privacy practices.

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  • Date*
     - -

  • Notice: Your health information related to work-related illnesses or injuries, or medical surveillance of the workplace may be disclosed to your employer.

  • Patient Medical History

  • Emergency Contacts

  • Format: (000) 000-0000.
  • Add Additional Emergency Contacts
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Present Medical History:

    Please indicate whether you have had any of the following medical problems (with approximate date of illness or diagnosis).
  • Blood Clots?*
  • Cancer?*
  • Concussion?*
  • Depression?*
  • Stroke?*
  • High Blood Pressure?*
  • Asthma?*
  • Heart Condition?*
  • Please identify the type of heart condition you have*
  • Migraines/Headaches?*
  • Diabetes?*
  • Please identify the type of diabetes you have*
  • High Cholesterol?*
  • Seizures?*
  • Do you have any other medical problems?*

  • Women's Gynocological History:

    Please enter the following information.
  • Are you currently on birth control?
  • Type of birth control you are currently taking:
  • Do you wish to discuss birth control options with your provider?
  • What type of birth control do you desire to discuss with you provider?
  • Was your last pap smear abnormal?*
  • Was your last mammogram abnormal?*

  • Family History:

    Please enter the following information for each family member, if able.

  • Social History

  • Advanced Directives

  • DNR?*
  • Living Will?*
  • Power of Attorney?*
  • Living Arrangements*
  • How often do you consume alcoholic beverages?*
  • How often do you use illicit drugs?*
  • How often do you use tobacco products?*

  • Authorization for Use and Disclosure of Protected Health Information (PHI)

  • Instructions: Please complete the form in full. If any section is incomplete, this authorization will be considered invalid.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Please identify the type of access you are requesting*

  • I understand that the requested information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency (HIV). It may also include information about behavioral or mental health services and treatment of alcohol and drug abuse.

  • Expiration: Unless otherwise revoked, this authorization shall expire upon this date: (choose date below) or no later than a year from the date on the authorization.
     - -

  • Statements of Understanding: 

    1. I understand that this authorization is voluntary and that I may refuse to sign it. 
    2. I understand that I may refuse to sign this authorization, and if I do not sign this form, my health care or payment for health care will not be affected. 
    3. I understand that once the disclosure authorized herein has be made, the information disclosed may be subject to re-disclosure by any receipt and no longer protected by federal privacy laws. 
    4. I understand that I may revoke this authorization at any time by delivering a written recovation to the Health Information Management department of McPherson Hospital. 
    5. I understand that if I revoke this authorization, it will have no effect on disclosures already made in reliance on this authorization. 
    6. I authorize the use and disclosure of the protected health information, as described. I have recieved a copy of this form. 
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  • Date*
     - -

  • Permission to Disclose

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • I authorize McPherson Medical and Surgical Associates to furnish any information, reports, or copies of records which may be requested by other doctors, hospitals, insurance companies, etc. 

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  • Date*
     - -

  • Patient Partnership Agreement

    At McPherson Medical and Surgical Associates, we are committed to providing youwith high-quality, compassionate care. To help us work together effectively,this agreement outlines mutual expectations that support a respectful andproductive healthcare relationship.

  • What You Can Expect From Us:

    • Professional, respectful, and compassionate care.
    • Clear communication and active listening.
    • A safe and welcoming environment.
    • Timely follow-up on appointments, test results, and treatment plans.

    What We Ask of You:

    • Respectful Communication & Conduct: We are here to help. We ask that you treat our providers and staff with the same respect and professionalism we strive to show you. We have a zero-tolerance policy for abusive language, threats, or physical aggression. Any form of disrespectful behavior may lead to dismissal from our practice.  
    • Appointment Attendance & Timeliness: Your time and health matter to us. Please arrive on time for your appointments. If you’re unable to attend or expect to be late, contact us as soon as possible-ideally 24 hours in advance-so we can adjust schedules and help others. Repeated no-shows or chronic lateness may affect your ability to remain in our care.
    • Visit Focus & Preparation: To avoid delays and ensure you receive appropriate attention, your appointment will focus on the primary concern that you articulated, in advance or when checking in for your appointment. If you have further needs, beyond the primary concern, we will help set an additional appointment to address further concerns.
    • Medications & Treatment Plans: We expect you to follow the treatment plans we create together. Take medications as directed and communicate any concerns or side effects. For long-term use of controlled substances, we may require a medication agreement to ensure safe and appropriate use.
    • Tests, Referrals, & Follow-Up Care: To ensure quality of care it is vital that you complete lab work, imaging, or specialist visits as recommended. Following this through helps us provide the most effective care possible.

    If expectations in this agreement are not met-including missed appointments, disrespectful conduct, or non-adherence to treatment this could result in discontinuation of care at our practice.

    By signing this agreement, you confirm that you’ve read and understood these expectations. This partnership is designed to ensure mutual respect, personalized care, and a professional healthcare environment that benefits everyone.

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