Patient Forms

New Patient Forms

• HIPAA Consent Acknowledgement
• Medicare Annual Visit Packet

Medical Records Forms:

If you wish to fax medical record requests, please print the form, complete and fax to
913-338-1311.

• Medical Records Release [from CPFCC to outside provider or self]
• Specialty Office Form Fee Guidelines

Billing payment records or ledgers without record copies: call the College Park Billing office at (913) 469-0503. Or fax written request to (913) 469-5267. There is no need to complete a Release of Information Form for billing reports.

Other Forms

Dermatology

• Health History Form

Functional Medicine Clinic

• Appointment Time Agreement
• Symptoms Questionnaire
• Intake Form

General Use

• Permission For Medical Treatment – Minor(s)

Imaging

• X-ray(s) Release Form | complete and fax to (913) 825-2765, or call 956-4200.

Neurology

• New MS Patient History Form

Orthopedic

• Dr. Gurley Second Opinion Info Request
• Dr. Humphrey Second Opinion Info Request

Pain Management

• Dr. Knoff: Health History Form
• Dr. Wheeler: Health History Form

Upper Endoscopy Procedure

• EGD Preparation Instructions