Patient Support

The following patient support and informational topics are also available:

1. Medical Records/ Authorization to Treat
2. Participating Insurance Companies
3. Registration Forms
4. Post Operative Instructions
5. Frequently Asked Questions

Medical Records/Authorization to Treat

Requesting Medical Records

We are happy to release your medical records to ensure continued medical care. Please print off and fill out our form below then send or fax it to us. It should include, along with the current date, the patients full name, date of birth, current contact phone number, and where you want the records sent. If the patient is a minor we require a parent's or guardian's signature.

> Medical Records Release Form

Please mail your request to:

Lawrence Otolaryngology Associates
Attn: Medical Records
1112 West 6th Street, Suite 216
Lawrence, Kansas 66044

Or you may fax them to:

(785) 841-1173
Attn: Medical Records

Please note that we require two working days to process your request.

Medical Records, Frequently Asked Questions

Q: Will you email my records to my physician office or myself?
A: No, for security reasons, we do not email records. However, we can mail them to your home or another physician's office.

Q: Can you fax my records?
A: Under the HIPAA security regulations, we are able to fax records to other physicians or to a secure fax number that you provide to us. Our office policy requires a signed authorization by the patient to do so.

Q: Who can I talk to regarding my medical records?
A: You may call (785) 841-1107 and leave a message regarding your request.

> See Our Privacy Policy

Authorization to Treat

If someone other than the parent or legal gaurdian (e.g. grandparent, aunt, uncle, friend) is bringing a minor in to be treated, you will have to bring in a authorization to treat form. Please print and fill out the form below and bring it to the appointment. If we do not have this form on file we wil not be able to treat the patient until we get it.

Authorization to Treat

Participating Insurance Companies

The following list is provided for informational purposes only, and is not a guarantee of our participation in these plans. Please call your insurance company for confirmation of our physicians' participation with your health plan.

• AETNA. All Physicians, No Hearing Aid Benefits
• BLUE CROSS OF KANSAS. All Plans
• PHP. All Physicians
• BLUE CROSS OF KC. All Physicians
• PREFERRED CARE BLUE NETWORK.
• PREFERRED CARE NETWORK.
• PREFERRED CARE BLUE NETWORK.
• BLUECARE NETWORK HMO.
• BLUE ADVANTAGE HMO.
• CENTURY HEALTH PLAN. All Physicians, Mary Sostarich
• CIGNA. All Physicians
• COVENTRY.
• FMH.
• PRINCIPAL.
• PHC OF KS. All Physicians
• FIRST GUARD. All Physicians
• HUMANA. All Physicians
• KANSAS MEDICAID. All Physicians
• MEDICARE. All Physicians
• PHCS. All Physicians
• PHS. All Physicians
• RR MEDICARE. All Physicians, No Hearing Aid Benefits
• TRICARE.
• UNITED HEALTHCARE. All Physicians
• WPPA.

Registration Forms

For your convenience, we have put our patient registration forms on our website. You may print these forms out and complete them prior to your visit.

> Health History Form

> Patient Information Form

> Accident & Worker's Comp Form

> Dizziness Questionaire for Dr Lee Reussner

> Dizziness Questionaire for Dr Robert Dinsdale

> Dizziness Questionaire for Dr Stephen Segebrecht

> Adult Ear Infection Questionaire for Dr Robert Dinsdale

> Child Ear Infection Questionaire For Dr Robert Dinsdale