Thank you for your interest in receiving care from one of our outstanding providers at McPherson Medical and Surgical Associates. Below is the new patient packet that we need filled out and returned before you are seen. Please fill out fully to the best of your ability. Once you have completed this packet, it will be sent automatically to the Patient Navigator Care Team.

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: 

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.

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

Instructions: Please complete the form in full. If any section is incomplete, this authorization will be considered invalid. Please print legibly. Use black or blue ink only. Do not use a pencil.

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.

Release Information To: 

Provider: _______________

McPherson Center for Health 

1000 Hospital Drive, Building 3

Ph: 620-241-7400

Fax: 620-241-6523

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. 

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. 

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.