Midlakes Physician Practice Services

Patient Forms

The following forms are provided as a service to the patients of Midlakes Management Corporation physician clients. (Midlakes physician clients are listed on the Clients page).

If you have been referred to this page by your doctor, the forms provided here most likely satisfy your doctor's requirements.

Click on the form title to open a PDF file for printing the form.
(*)Requires Acrobat Reader available here.

Medical Records Transfer
To authorize and request the transfer your medical records from one doctor/healthcare provider to another doctor/healthcare provider.

Patient Registration
Use this form to provide your personal (address, phone numbers, etc.) and health insurance information for your doctor when you are a new patient or to update your information when there are changes.

Filling out this form before going to your appointment will save time filling it out after you get to your doctor’s office or avoid having to verbally update the information with office staff at the time of your appointment.

Authorization For Use and Disclosure Of Protected Health Information - Family
Authorizes your doctor or healthcare provider to discuss your health issues and treatment with specifically designated family members.

Authorization to Discuss Personal Healthcare Billing or Financial Information
Authorize specific individuals, such as a spouse, child or parent, to discuss your healthcare financial information. This is required if someone other than yourself is involved with your doctor’s bills and needs to discuss them on your behalf.

If you are interested in more information about becoming a client,
please contact us via email or call us at (315) 462-9482