Patient Forms

Medical Records

If you have been a patient at Olathe Medical Center (OMC) and would like to request a copy of your medical records, please complete the authorization form. Please read through this form carefully and be certain to fill out ALL areas of the form completely.  Failure to do so may mean that we will not be able to process your request.  If you need help with completing the form, please feel free to call us at 913-791-4200 ext.4632.  Once completed, you can fax the form back to us at 913-791-4335 or mail it to us at Health Information Management Department/Release of Information, Olathe Medical Center, 20333 W. 151st Street, Olathe, KS, 66061.

Please note:  If the records you request total more than 10 pages, you will be charged $.60 per page (there is an additional fee for records stored on microfilm).  You will receive an invoice for these charges via mail from HealthPort, the Release of Information vendor used by Olathe Medical Center.  We are not able to send records directly to an insurance company or attorney’s office without a request from that office for the records.  The request must include a statement from the requester that they agree to pay for any charges incurred for the reproduction of the requested records.

 

If you have been a patient at Miami County Medical Center (MCMC) and would like to request a copy of your medical records, please complete the authorization form and return to the Health Information Management department at MCMC. Please read through this form carefully and be certain to fill out ALL areas of the form completely.  Failure to do so may mean that we will not be able to process your request.  If you need help with completing the form, please feel free to call us at 913-294-6703.  Once completed, you can fax the form back to us at 913-294-5919 or mail it to us at Health Information Management Department/Release of Information, Miami County Medical Center, 2100 Baptiste Dr./P.O. Box 365, Paola, KS  66071.

Please note:  You will be charged $.60 per page (there is an additional fee for records stored on microfilm).  You will receive an invoice for these charges via mail from HealthPort, the Release of Information vendor used by Miami County Medical Center.  We are not able to send records directly to an insurance company or attorney’s office without a request from that office for the records.  The request must include a statement from the requester that they agree to pay for any charges incurred for the reproduction of the requested records.

 

The Birth Place

The Birth Place pre-registration form should be completed and returned to the Birth Place Pre-admission Coordinator, or faxed to the Admissions Office at 913-791-4454. To make a pre-admission appointment, please contact the scheduling office at 913-791-3500, ext. 4128. Patients are encouraged to make their appointments between the 30th and 33rd week of pregnancy.

Rehabilitation Services

Based on the form(s) you were instructed to complete below, print the form, fill it out, then bring it with you to your first therapy appointment.  Thank you!

  • Registration Form
    To be completed by patients before coming for outpatient Physical Therapy, Occupational Therapy, or Speech Language Pathology.
  • PT-OT Intake Form
    To be completed by patients coming for outpatient Physical Therapy and Occupational Therapy
  • Women's Health Intake Form
    To be completed by patients coming to Physical Therapy specifically for women's health issues, such as back pain during pregnancy, pelvic pain and/or urinary incontinence issues.
  • Men's Health Intake Form
    To be completed by patients coming to Physical Therapy specifically for men's health issues, such as pelvic pain and/or urinary incontinence issues.
  • Vestibular (Dizziness) Intake Form
    To be completed by patients coming to Physical Therapy specifically for vestibular (dizziness) problems.
  • SLP Outpatient Intake Form
    To be completed by patients before coming for Speech Language Pathology (Speech Therapy).
  • Lymphedema Intake Questionnaire
    To be completed by patients coming for therapy for lymphedema.

Financial Assistance

Pre-Operation for Surgical Services

If you are scheduled for an upcoming surgical procedure at Olathe Medical Center, please download the appropriate form below. The pediatric form is for patients 13 years of age and younger.