MidAmerica Patient Forms

Download Your Patient Forms

• For Patients of Dr. Brisbin, Dr. Chapman, Dr. Fakhouri, Dr. Gourineni, Dr. Kronen, Jeremy Bell PA-C and Kelly Hermann PA-C

  • Patient Registration and Health History Form

• For Patients of Dr. Sarkis Bedikian

  • Patient Registration and Health History Form

• For Patients of Dr. Adam Meisel and Jon Schwermer PA-C

  • Patient Registration and Health History Form

• For patients of Dr. Svetlana Zats:

  • Patient Registration and Health History Form

• For Patients Scheduled for a Magnetic Resonance Imaging (MRI) Scan

  • MRI Screening Form

• Scheduling Minors

  • Permission to Accompany A Minor Form

• Notice of HIPAA Privacy Practices

  The HIPAA Privacy Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. You will be given a copy of our HIPAA Privacy Notice prior to your visit, and be asked to sign that you received it.

  • Notice of HIPAA Privacy Practices