Midwest Allergy & Asthma understands that medical information about you and your health is personal. Our team is committed to protecting your medical information or protected health information (PHI). We create a record of the care and services you receive by our team of medical professionals. We need this record to provide your care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Midwest Hearing Aid Systems.
If you have any questions regarding your protected health information, please contact our business office at (651) 702-0750.
Midwest Allergy & Asthma is dedicated to providing you the highest quality of health care at the best value. We are also dedicated to protecting you and your family’s medical records. If you have any questions regarding the completion of the below forms, please reach out to our medical records at (651) 702-0750.
Authorization for Release of Information
Authorization for Share Protected Health Information
Consent to Provide Treatment for a Minor Child
HIPAA Request for Amendment to Records
HIPAA Request for Private Handling of Health Information Asthma Fact Sheet
OutsideSerum Refill ORDER CONSENT 2014
Outside Pre-injection Questionnaire 2014
FMLA, Insurance, Disability and Other Patient Requested Forms
We are happy to assist you in the completion of your required forms. Insurance forms, disability forms, Family Medical Leave Act forms, Return to Work forms, etc. are completed and processed by our clinical staff and not our surgical staff. Midwest Allergy & Asthma has a standardized form for FMLA and Disability Paperwork. If your employer accepts this standard fee these Midwest Allergy & Asthma forms are completed at no cost to the patient. If your employer will not accept our forms, a $10.00 administrative fee will be charged for each non-Midwest Allergy & Asthma form completed.
Please be aware, on the day of your surgery, your physician will not accept any of these forms. For your physician to better assist you in the completion of your forms in a more timely manner you should mail them to our clinic in Woodbury. Please do not hand deliver them to the clinic where you were last seen.
Please mail your forms to:
Midwest ENT Specialists
ATTN: Medical Records
2080 Woodwinds Drive, Suite 120
Woodbury, MN 55125.