Blue Springs
205 NW R.D. Mize Rd.
Suite 304
Blue Springs, MO 64014
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Independence
11200 Winner Road
Independence, MO 64052
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Higginsville
1717 N. Main Street
Higginsville, MO  64037
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Appointments: (816) 655-0102
Phone:  (816) 228-4770
Fax:  (816) 228-1156
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Connect with us anytime
through the patient portal. Schedule apptointments,
online billpay, talk to a nurse,        and much more
.
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Click here to let us know about your recent experience in our office.

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Are you expecting?
Find out how to schedule a prenatal visit.

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Click here to pay your bill.

  

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Patient Forms 

New patients may choose to print the following forms to be filled out prior to your appointment.  Please bring the completed form(s) with you to your appointment.  Also if you have had an address or insurance change you may be required to complete the information sheet again.  Please call us if you have any questions about completing these forms.


If you have commercial insurance you will need to complete the patient information sheet and the HIPAA privacy policy acceptance form.  If you have insurance through the state (i.e. Medicaid) you will need to fill out the VFC (Vaccines for Children) form as well.


If you are requesting copies of your child's chart or requesting that your child's chart be transferred, you will need to complete the medical records request form and either fax, mail or bring it into the office.  Charges will apply for those needing to transfer their entire record.  If you have questions regarding the status of your records please call DataFile Technologies: 816-437-9134

If your child is 18 years and over and needs to give consent for the parents / legal guardians to have access to his chart, you will need to have the patient sign the form below to grant that permission.


To contact Medical Records
Phone:  816.655.0167
Fax:       816.655.0156

If you need Adobe Reader to print forms, click here to access the free download.

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