Forms
New Clinic Patient  (click to print all)
  • New patient registration 
  • New patient self-reporting history 
  • Patient financial policy
  • Privacy policy
  • Signature page


Transfer Records(click)

HIPPA notice of privacy practices (click)

Request to inspect or copy PHI(click)

Reqest for confidential communication or PHI (click)

Notice of nondiscriminatinon and accessibility requirements (click)



These forms use Adobe PDF
dowload Abode here
 
We hope you will spend some time organizing your thoughts with our forms:
The majority of our patients print the forms online and have them filled out when they arrive.  When we get a referral from your doctors office we usually try to call you right away to set up the appointment and direct you to the website for forms.
                                                                                          



Printer not working?  That's ok, just call.
If you would like us to mail to you our new patient forms we'd be glad to assist you -- please phone ahead.


(913) 432-4355  We will see you soon!
Prairie Surgical Care
General and Minimally Invasive Surgery
Carlo Jurani, M.D    Lingbo Fan, M.D.