Getting Ready for your first visit to My Heart Partners

We have included forms on this page that need to be filled out prior to your first visit. It will be more convenient for you to complete these pages at home. It is important to My Heart Partners that you spend as little time as possible in the waiting room.

The first item, and most urgent, is the Authorization for Release of Medical Records. This needs to be completed and mailed right away so that we can request all your medical files before your scheduled appointment. We will need a separate request for each doctor’s office or medical facility. (Some medical facilities may be slow in responding, so we need to make the requests as early as possible.)

The Insurance & Payment Policy form discusses policies that My Heart Partners abides by to keep its clinics running smoothly and efficiently.

Next, the Review of Symptoms form allows the staff of My Heart Partners to gain a general sense non-cardiac health issues you may be having.

By sharing your Cardiac History, we gain valuable information about any past cardiac procedures you may have undergone. 

The Social History form asks for information regarding your family and current medical illnesses.

Signing the Medical Consent form allows My Heart Partners to use or disclose your identifiable health information when necessary in order to ensure that you, the patient, receives the best treatment promptly.

Finally, Patient Demographics confers all of your basic information such as name, date of birth and address to My Heart Partners.

Each form can be printed from this website right on your home computer printer. Click here if you would like to print all of the forms at once.

You may also request that we mail you the forms, on our contact page. We would be happy to do this if you prefer.

Should you have any questions as you complete each item, please call My Heart Partner Mike for assistance at 269.428.4620.

Remember that by completing and mailing these forms in advance of your appointment, your first visit will be less stressful and more efficient.

To display the forms in PDF format, you must have Adobe Acrobat Reader, a free plug-in that can be found at: Adobe.com