Practice Overview, Mission Statement and Hospital Affiliations
IIMC and CRSM Physician Listing
Laboratory, Bone Density, X-Rays and Pulmonary Function Testing
Human Resources and Employment Center
Practice Hours and Contact Information, Location Map, Scheduling Appointments, Emergencies and After Hours, Refills, Requesting Medical Records
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We are happy that you chose the Indiana Internal Medicine Consultants and Center for Respiratory & Sleep Medicine for your care and concerns. In this section, we house a variety of forms that you may need to fill out , whether you are a new patient or coming in for a visit. Each form is accessible in a PDF format for you to download and fill out before arriving.

Our information is available in a PDF format. If you do not have Acrobat Reader, please click the icon to download.
Patient Information Form

New patients must fill out this form so we can start a file and keep them current. You will be given this form when you visit the office or you may download the form from the web site.
Health Questionnaire Form

Patients must complete this form so we can keep an accurate profile of your medical history and your current condition. You will be given this form when you visit the office or you may download the form from the web site.
HIPPA Form

Patients must fill out a HIPPA Permission To Disclose Information form. You will be given this form when you visit the office or you may download the form from the web site.
Medical Record - Release of Information Form

The charge is $15.00 for the first 10 pages. There is an additional charge of $0.25 per page after the first 10.

A Release of Information Authorization form must first be completed by the patient or legal guardian prior to requesting medical records.