[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-567600-105":3,"detail-sidebar-cat-1-en-105":74,"doc-detail-567600-en":120},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":67,"head_meta":69,"extra_data":71,"updated_unix":73},105,"en","new-patient-paperwork-packet-pulmonary-updated-02092022-w-new-address-1-patient-check-in-phi-release-authorization-packet","NEW-Patient-Paperwork-Packet-PULMONARY-Updated-02092022-w-New-Address-1 - Patient Check-in & PHI Release Authorization Packet","","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.",{"@graph":14,"@context":66},[15,34,49],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/new-patient-paperwork-packet-pulmonary-updated-02092022-w-new-address-1-patient-check-in-phi-release-authorization-packet/567600/",4,{"url":32,"name":10,"@type":35,"author":36,"headline":10,"publisher":39,"fileFormat":42,"inLanguage":8,"description":12,"dateModified":43,"datePublished":43,"encodingFormat":42,"isAccessibleForFree":44,"interactionStatistic":45},"DigitalDocument",{"name":37,"@type":38},"kopisore","Person",{"url":19,"name":40,"@type":41},"DocShare","Organization","application/pdf","2026-10-13",true,{"@type":46,"interactionType":47,"userInteractionCount":4},"InteractionCounter",{"@type":48},"ViewAction",{"@type":50,"mainEntity":51},"FAQPage",[52,58,62],{"name":53,"@type":54,"acceptedAnswer":55},"What should patients bring to the upcoming pulmonary appointment?","Question",{"text":56,"@type":57},"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.","Answer",{"name":59,"@type":54,"acceptedAnswer":60},"Are there any instructions when entering the clinic offices?",{"text":61,"@type":57},"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.",{"name":63,"@type":54,"acceptedAnswer":64},"How does the PHI authorization work in this packet?",{"text":65,"@type":57},"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.","https://schema.org",{"og:url":32,"og:type":68,"og:title":10,"og:site_name":40,"og:description":12},"article",{"robots":70,"canonical":32},"index,follow",{"doc_id":72,"site_id":7},567600,1791867104,{"code":4,"msg":75,"data":76},"success",[77,82,87,92,97,102,106,111,116],{"id":78,"doc_module":22,"doc_module_name":25,"category_name":79,"show_sort_weight":80,"slug":81},11,"Presentations",90,"presentations",{"id":83,"doc_module":22,"doc_module_name":25,"category_name":84,"show_sort_weight":85,"slug":86},12,"Resumes",80,"resumes",{"id":88,"doc_module":22,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},14,"Invoices",70,"invoices",{"id":93,"doc_module":22,"doc_module_name":25,"category_name":94,"show_sort_weight":95,"slug":96},15,"Posters",60,"posters",{"id":98,"doc_module":22,"doc_module_name":25,"category_name":99,"show_sort_weight":100,"slug":101},16,"Social Media",50,"social-media",{"id":103,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":104,"slug":105},17,40,"forms",{"id":107,"doc_module":22,"doc_module_name":25,"category_name":108,"show_sort_weight":109,"slug":110},18,"Letters",30,"letters",{"id":112,"doc_module":22,"doc_module_name":25,"category_name":113,"show_sort_weight":114,"slug":115},21,"Paper Templates",5,"papers-templates",{"id":117,"doc_module":22,"doc_module_name":25,"category_name":118,"show_sort_weight":4,"slug":119},158,"General","general-158",{"code":4,"msg":75,"data":121},{"doc_id":72,"user_id":122,"nickname":37,"user_avatar":123,"doc_module":22,"category_id":103,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":124,"file_id":125,"file_url":126,"file_type":127,"file_size":128,"view_count":4,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":78,"language":129,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":130,"faqs":131,"seo_title":132,"seo_description":12,"update_tm":73,"read_time":33},962090880963,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Robert W. Schriner, MD, FCCP, FAASM  \nMichael D. Wilons, MD Kenneth Azuka Okpor, MD, FCCPIstvan D. Wollak, MD, FCCP Jeffrey Wright, MD, PhD, FCCP Todd M. Henderson, MD, FCCPYadana Kyaw, MD  \nRavis Curry, MD  \nJulia H. Barton, MD  \nHaitham El-Haddad, MD Muhammad M. Sheikh, MD Anurag Mehrotra, MD  \nPraneet Iyer, MD  \nObaid Awan, MD George W. Williams, II, DO Precious Macauley, MD Jonathan M. Davis, MD  \nG. Matthew Hinnant, DO  \nStephanie 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  \nC. Will Shorter, DNP, AGACNP-BC Jonathan Hawkins, PA-C, MSPAS Crystal Wilkerson, DNP, AGACNP-BC Michael Lipscomb, PA-C  \nJenna Richardson, MSN, AGACNP-BC Jasmine Lester, MSN, FNP-CVladyslava Inman, DNP, AGACNP-BC Michelle Samarin, DNP, AGACNP-BC  \nAPPOINTMENT DATE:   CHECK-IN TIME:    \nLOCATION:  2120 Exeter Rd, Suite 250, Germantown, TN 38138  \nPH: 901-767-5864 FAX: 901-767-6591  \n(Located above OrthoSouth, next to Trader Joes, in the Baptist Medical Group building)  \n401 Southcrest Cir, Suite 212, Southaven, MS 38671  \nPH: 662-349-0488 FAX: 662-349-5974 (Go straight in sliding glass doors, take elevator to 2, go Left)  \n*PLEASE ARRIVE AT THE CHECK-IN TIME LISTED ABOVE, BUT DO NOT ARRIVE MORE THAN 30 MINUTES PRIOR.*  \nBelow 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  \nwhen you arrive.  \n Insurance cards and Photo ID  \n Records from your referring physician (if they have not been faxed to us)  \n Paperwork from this packet (PLEASE FILL OUT BEFORE APPOINTMENT)  \n Any pertinent records for your visit including any hospitalizations or ER visits in the past six (6) months  \n 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.)  \nYou MUST bring this paperwork filled out entirely in order to be seen.  \n* IMPORTANT NOTICE!  \nWhen 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.  \nBaptist Medical Group Inc. (BMG)  \nAuthorization to Release PHI  \nPhysician Practices  \nBaptist Clinic Name: Memphis Lung Physicians Foundation Phone \\#  901-767-5864  Fax\\# 901-767-6591  Address: 2120 Exeter Rd, Suite 250, Germantown, TN 38138   \nPATIENT'S NAME:   BIRTH DATE:   Chart \\#: ~~ ~~  \nPATIENT’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   \nI authorize Baptist or the following person or organization (specify if applicable)   to:  \n􀀀 disclose my health information to:    \n(Name and Address) -Specify: Attorney, Insurance, Self, etc  \n􀀀 obtain/request copies of my health information from:    \n(Name and Address) -Specify: Hospital, Doctor, etc  \nPurpose of use, disclosure, and or request: 􀀀 Continuation of Care/Treatment 􀀀 Attorney 􀀀 At the request of the patient 􀀀 Payment 􀀀 Other,  \nspecify:    \nI authorize use and/or disclosure of information covering treatment from:   to:    \n(enter specific dates)  \nInformation to be used and/or disclosed:  \n􀀀 History and Physical 􀀀 Progress Note 􀀀 Lab 􀀀 Radiology/Imaging 􀀀 All records 􀀀 Itemized bill  \n􀀀 Other (Specify):    \nI 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","cbCaimJGx5qkSiP7","https://ap.wps.com/l/cbCaimJGx5qkSiP7","pdf",675798,"English","# Appointment and check-in information\n## Location details and arrival timing notice\n# Checklist of items to bring\n## Required records and imaging instructions\n# Important patient notice\n## Fragrance restriction for asthma/COPD\n# PHI release and patient information\n## Authorization to disclose and obtain records\n## Covered information, purposes, and expiration","[{\"question\":\"What should patients bring to the upcoming pulmonary appointment?\",\"answer\":\"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.\"},{\"question\":\"Are there any instructions when entering the clinic offices?\",\"answer\":\"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.\"},{\"question\":\"How does the PHI authorization work in this packet?\",\"answer\":\"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.\"}]","NEW-Patient-Paperwork-Packet-PULMONARY-Updated-02092022-w-New-Address-1 - Patient Check-in & PHI Release Authorization Packet | PDF"]