Online Payments - Midwestern University Clinics

Referral Information

Additional Information / Accommodations Needed

Upload Patient Records (If Applicable)

Maximum upload size: 1.54MB

Patient Information

Name *

Date of Birth *

Address *

Address

Street Address

Address

City

State

Zip Code

Phone *

Insurance *

Referring Provider

Name *

Address *

Address

Street Address

Address

City

State

Zip Code

Phone *

Fax

Authorization

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *

Referral Information

Additional Information / Accommodations Needed

Upload Patient Records (If Applicable)

Maximum upload size: 1.54MB

Patient Information

Name *

Date of Birth *

Address *

Address

Street Address

Address

City

State

Zip Code

Phone *

Insurance *

Referring Provider

Name *

Specialty *

Address *

Address

Street Address

Address

City

State

Zip Code

Phone *

Fax

Authorization

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *

Patient Information

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Address *

Address

Requested Information / Documents

Type of Documents *

Dental Records

Radiographic Images

Photographs

OtherOther

Dental Document Details

HIV / AIDS diagnosis, treatment or testing information

Behavioral Health Notes

Alcohol or drug abuse treatment information

Authorization

This authorization will expire 1 year from 06/03/2023.

I understand I may withdraw my authorization at any time by submitting a written request to the HIPAA Privacy Officer. I understand any revocation is not effective to the extent action has already been taken in reliance on this authorization. I understand information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law. This authorization is not intended to affect a patient's ability to receive medical care.

Alcohol and Drug Abuse Treatment.
To the extent my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize the disclosure of such information or record.

HIV / AIDS Information
To the extent my medical record contains information regarding my HIV/AIDS status, treatment or testing, I authorize the disclosure of such information or record.

Behavioral Health Notes / Record
I authorize the disclosure of any behavioral health notes or information in my medical record.

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *

Referral Information

Referring Name Facility *

Referring Dentist *

Referring Dentist Email Address *

Facility Phone Number *

Patient Information

Patient Name *

Sex *

Female

Male

Other

Patient Date of Birth

Patient Mailing Address *

Patient Mailing Address

Street Address

Patient Mailing Address

City

State

Zip Code

Patient Email Address *

Patient Phone Number *

Emergency Contact Name *

Emergency Contact Phone Number *

Authorization

Community Partner site to email this completed form to communitypartners@midwestern.edu. Midwestern will
contact the patient to schedule an appointment within 48 business hours of receipt.

Midwestern will reserve an appointment time for the patient. The length of time to complete your agreed upon
treatment depends on the individual needs of each patient. As a teaching facility, care will require longer
appointments than you may be accustomed to in a private dental office. Additionally, procedure completion may
require more than one appointment. Valid ID is required for patient registration.
Patient referral is valid for 30 days from date of referral on form and patient must be seen within those 30 days.
If patient is taking medications, please remind them to bring a list to their appointment.
Patient must be screened and accepted into the dental program prior to any treatment. For the no charge endodontic
Community Partner therapy program, the patient will be provided with a limited exam and radiograph.
Retreatments are not a covered benefit under the Community Partners endodontic therapy program.
Some complex cases may be determined to be a non‐teaching case and outside the scope of the program.
If patient does not require endodontic therapy, patient will be referred back to referring dentist for treatment.
If patient is provided with endodontic therapy, the patient understands that treatment will include a restoration [core] to
temporarily protect the tooth, at no charge to the Community Partner patient. Please note the tooth may still need additional
definitive treatment.
Patient understands that this referral is for potential limited treatment only for the listed tooth on the referral and the
patient may choose to return for comprehensive care at our clinic.
Patient must provide a current valid government issued photo ID.

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *