NEW-Patient-Paperwork-Packet-PULMONARY-Updated-02092022-w-New-Address-1 - Patient Check-in & PHI Release Authorization Packet

Oct 13, 2026

Pulmonary clinic new-patient paperwork packet collecting essential registration and check-in details, including appointment date, check-in time, and clinic locations with phone and fax numbers. Includes a comprehensive bring-list covering insurance cards, photo ID, records from referring physicians, completed packet forms before the visit, and outpatient testing documentation from prior months and years, with imaging requirements. Contains an important notice on avoiding strongly scented fragrances due to asthma/COPD triggers. Features a patient information section and a HIPAA authorization to release and obtain PHI for specified purposes, information types, covered diagnoses, expiration, revocation rights, and acknowledgment of re-disclosure risk.

LanguageEnglish

CategoryForms

FormatPDF

Pages11

Reading Time4 min

AccessFree to download

Appointment and check-in information

Location details and arrival timing notice

Checklist of items to bring

Required records and imaging instructions

Important patient notice

Fragrance restriction for asthma/COPD

PHI release and patient information

Authorization to disclose and obtain records

Covered information, purposes, and expiration

Robert W. Schriner, MD, FCCP, FAASM Michael D. Wilons, MD Kenneth Azuka Okpor, MD, FCCPIstvan D. Wollak, MD, FCCP Jeffrey Wright, MD, PhD, FCCP Todd M. Henderson, MD, FCCPYadana Kyaw, MD Ravis Curry, MD Julia H. Barton, MD Haitham El-Haddad, MD Muhammad M. Sheikh, MD Anurag Mehrotra, MD Praneet Iyer, MD Obaid Awan, MD George W. Williams, II, DO Precious Macauley, MD Jonathan M. Davis, MD G. Matthew Hinnant, DO Stephanie Lamar, RN, MSN, FNP-C Shannon Woods, RN, AGPCNP-BC Amy Thomas, RN, MSN, FNP-C Jenna Scruggs, RN, MSN, FNP-C Jennifer Gatlin, RN, MSN, AGPCNP-BC Thomas Shapaker, PA-C C. Will Shorter, DNP, AGACNP-BC Jonathan Hawkins, PA-C, MSPAS Crystal Wilkerson, DNP, AGACNP-BC Michael Lipscomb, PA-C Jenna Richardson, MSN, AGACNP-BC Jasmine Lester, MSN, FNP-CVladyslava Inman, DNP, AGACNP-BC Michelle Samarin, DNP, AGACNP-BC APPOINTMENT DATE: CHECK-IN TIME: LOCATION: 2120 Exeter Rd, Suite 250, Germantown, TN 38138 PH: 901-767-5864 FAX: 901-767-6591 (Located above OrthoSouth, next to Trader Joes, in the Baptist Medical Group building) 401 Southcrest Cir, Suite 212, Southaven, MS 38671 PH: 662-349-0488 FAX: 662-349-5974 (Go straight in sliding glass doors, take elevator to 2, go Left) *PLEASE ARRIVE AT THE CHECK-IN TIME LISTED ABOVE, BUT DO NOT ARRIVE MORE THAN 30 MINUTES PRIOR.* Below is a checklist of items that you need to bring to your upcoming appointment. Please be sure to bring each item, as this will save time when you arrive. Insurance cards and Photo ID Records from your referring physician (if they have not been faxed to us) Paperwork from this packet (PLEASE FILL OUT BEFORE APPOINTMENT) Any pertinent records for your visit including any hospitalizations or ER visits in the past six (6) months ALL outpatient testing records for any tests that you have had within the past two (2) years; includes CT scans of your chest, PET scans, Chest X-Rays, Lung Scans, Swallow Tests, Echocardiograms, Right Heart Caths, etc.(For any imaging, we must have the images on a disc and we must also have a copy of the report.) You MUST bring this paperwork filled out entirely in order to be seen. * IMPORTANT NOTICE! When entering the Memphis Lung Physicians Foundation offices, please refrain from wearing perfumes, colognes, fragrance lotions, fragrance creams, essential oils, etc. that have a strong smell. These fragrances can and will trigger asthma attacks and/or COPD exacerbations for some patients and employees. Thank you for your cooperation with this. Baptist Medical Group Inc. (BMG) Authorization to Release PHI Physician Practices Baptist Clinic Name: Memphis Lung Physicians Foundation Phone \# 901-767-5864 Fax\# 901-767-6591 Address: 2120 Exeter Rd, Suite 250, Germantown, TN 38138 PATIENT'S NAME: BIRTH DATE: Chart \#: ~~ ~~ PATIENT’S ADDRESS: Phone \#: Last 4 digits of SS \#: ~~ ~~I authorize MLPF to leave a message at the phone number(s) I have provided. YES NO I authorize Baptist or the following person or organization (specify if applicable) to: 􀀀 disclose my health information to: (Name and Address) -Specify: Attorney, Insurance, Self, etc 􀀀 obtain/request copies of my health information from: (Name and Address) -Specify: Hospital, Doctor, etc Purpose of use, disclosure, and or request: 􀀀 Continuation of Care/Treatment 􀀀 Attorney 􀀀 At the request of the patient 􀀀 Payment 􀀀 Other, specify: I authorize use and/or disclosure of information covering treatment from: to: (enter specific dates) Information to be used and/or disclosed: 􀀀 History and Physical 􀀀 Progress Note 􀀀 Lab 􀀀 Radiology/Imaging 􀀀 All records 􀀀 Itemized bill 􀀀 Other (Specify): I understand that the disclosure of my personal health information may include information regarding diagnosis and/or treatment for any of the following: alcohol abuse, drug abuse, psychiatric or mental illness, and/or sexually transmitted diseases, including Human Imm

FAQs

What should patients bring to the upcoming pulmonary appointment?

Bring insurance cards and photo ID, any records from the referring physician (if not already faxed), and the completed paperwork packet before the appointment. Also bring pertinent records from the prior six months and all outpatient testing records from the prior two years, including required imaging documentation.

Are there any instructions when entering the clinic offices?

Patients are instructed to refrain from wearing perfumes, colognes, fragrance lotions, fragrance creams, essential oils, and other strong-smelling fragrances, as these can trigger asthma attacks and/or COPD exacerbations for some patients and employees.

How does the PHI authorization work in this packet?

The packet includes an authorization for Memphis Lung Physicians Foundation/Baptist to disclose and/or obtain health information for specified purposes and with specified types of records. It explains that disclosure is voluntary, how revocation must be submitted, the authorization expiration timeframe, and the potential for re-disclosure by the recipient not protected under federal confidentiality laws.

Oct 13, 2026

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