Malik Rheumatology logo

(316) 558-8788   (316) 558-8775 (Fax)


2260 N. Ridge Rd.

Suite 210

Wichita, KS  67205


Malik Rheumatology, P.A.






I, the undersigned, certify that I (or my dependent) have insurance coverage with

and assign directly to Dr. insurance benefits, if any, otherwise payable to me for services rendered.

I understand that I am financially responsible for all charges whether or not paid by insurance.
I hereby authorize the doctor to release all information necessary to secure the payment of benefits.
I authorize the use of this signature on all insurance submissions.

Have you ever been diagnosed with the following? (Please circle those that apply) Please indicate year diagnosed if known.

  • Anxiety
  • Ankylosing Spondylitis
  • Cancer
  • Claustrophobia
  • COPD/Asthma
  • Crohn’s Disease
  • Depression
  • Diabetes/Hypertension
  • Fibromyalgia
  • Gout/Pseudogout
  • Heart Disease
  • Hepatitis B or C / HIV
  • Hyperlipidemia
  • Hypothyroidism
  • Hyperthyroidism
  • Iritis or Uveiitis
  • Irritable Bowel Syndrome
  • Juvenile Inflammatory Arthritis
  • Kidney Disease
  • Liver Disease
  • Lupus
  • Mitral Valve Prolapse
  • Obstructive Sleep Apnea
  • Osteoarthritis
  • Osteoporosis
  • Panic Attacks
  • Pericarditis
  • Pleuritis/Pleurisy
  • Polymyalgia Rheumatica
  • Psoriasis
  • Psoriatic Arthritis
  • Raynaud’s Syndrome
  • Reactive Arthritis
  • Rheumatoid Arthritis
  • Scleroderma
  • Sjogren’s Syndrome
  • Sexually transmitted disease
  • Ulcerative Colitis

Have you undergone any of the following surgeries? Please indicate date of surgery.

Do you have a family history of? (Please circle those that apply)

  • Ankylosing Spondylitis
  • Crohn’s Disease
  • Depression
  • Fibromyalgia
  • Gout/Pseudogout
  • Juvenile Inflammatory
  • Lupus
  • Osteoarthritis
  • Osteoporosis
  • Psoriasis
  • Reactive Arthritis
  • Rheumatoid Arthritis
  • Scleroderma
  • Sjogren’s Disease
  • Ulcerative Colitis

Doctor’s Notes:

List of all current medications:

  • Medications Strength
  • Dose
  • Date started

Medication allergies and reaction

  • Medication
  • Reaction

Doctor’s Notes:

I), understand that as part of my health care, MALIK RHEUMATOLOGY, P.A. originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment, • A means of communication among the many health professionals who contribute to my care, • A source of information for applying my diagnosis and surgical information to my bill • A means by which a third-party payer can verify that services billed were actually provided, and • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent, • The right to object to the use of my health information for directory purposes, and • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations

I understand that MALIK RHEUMATOLOGY, P.A. is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that MALIK RHEUMATOLOGY, P.A. reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should MALIK RHEUMATOLOGY, P.A. change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, email).

I wish to have the following restrictions to the use or disclosure of my health information:

I give permission to leave a message via telephone answering machine/voicemail or family member regarding appointment reminders and/or medical information if necessary.

I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.

I fully understand and accept / decline the terms of this consent.


[ ] Consent received by on

[ ] Consent refused by patient, and treatment refused as permitted.

[ ] Consent added to the patient’s medical record on

Malik Rheumatology, P.A.
2260 N Ridge Road, Suite 210
Wichita, KS 67205

Patient Financial Policy

Please bring your insurance identification card(s) with you each time you visit our office. A photocopy will be placed in your patient file. If you belong to an PPO/HMO plan, please make sure you have obtained a referral from your primary care physician.

Malik Rheumatology, P.A. participates with several insurance companies. It is up to the patient to be aware if we are a contracting/in-network provider with their insurance company. As a courtesy to our patients, if acceptable insurance identification is provided and effective coverage is verified, we will submit claims on your behalf.

All co-payments are due in full at the time of service. After we receive payment from your insurance company, any remaining patient balance is to be paid within 30 days of receipt of your statement unless monthly payment arrangements have been made. All patient balances are due within 90 days of receipt. Any questions regarding a non-payment from your insurance company should be directed to your insurance carrier.

Patients who do not have insurance coverage will be expected to pay at the time of service. If you cannot pay in full, a deposit will be required and we will work with you to set up a payment plan. A New Patient consult/office visit requires a $200.00 deposit payment at time of service for those who do not have insurance coverage or are considered self-pay.

We accept personal checks, money orders, cash and credit/debit cards (with the exception of American Express). Checks returned for insufficient funds will be charged a $25.00 service fee.

Delinquent accounts may be assigned to a collection agency or subject to small claims court action. All collection costs will be added to your outstanding balance and will become an additional cost to you. Any payments on accounts turned to collections are payable and due to the collection agency.

Our office policy requires a 24 hour cancellation notice. A service fee, as follows, applies to cancellations not made within the 24 hour time frame and “No Show” appointments:
Follow-up appts: $25.00
New Patient appts: $50.00

If you have any questions or need assistance in understanding your statement and/or insurance payments, please contact the office at (316)558-8788.

Patient Authorization to Use or Disclose Protected Health Information
To Primary Care Physicia

I, , understand that as part of my treatment, MALIK RHEUMATOLOGY, P.A. may forward protected health information to the primary care physician. I have read this authorization and understand what information will be used or disclosed, who may use and disclose the information, and the recipient(s) of that information. I specifically authorize any current employee or owner of MALIK RHEUMATOLOGY, P.A. to release or disclose my protected health information to the primary care physician or other medical practice named below. I understand that when the information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected health information. I further understand that I retain the right to revoke this authorization, if done so according to the steps set forth below.

Description of the information to be used or disclosed (check all that apply):

[ ] The patient’s entire medical record
(Note: This requires an explanation why the entire record may be disclosed).

[ ] The patient’s demographic information {check all that apply):
[ ] Name [ ] Address [ ] State/Zip Code only [ ] Telephone
[ ] Age [ ] Gender [ ] Race [ ] Other:

[ ] Medical Data/Information as related to:
[ j Specific condition (s):
[ ] Specific professional services(s):
[ ] Specific medication(s):
[ ] Other:

[ ] Other:

Name of the primary care physician or other medical practice, address, and fax number:

MALIK RHEUMATOLOGY, P.A. shall send information ONLY to the above address or fax number. Any disclosure of the patient’s protected health information to another address or fax number will require a separate authorization.

Purpose(s) of the information:

[ ] To permit MALIK RHEUMATOLOGY, P.A. to release any and all appropriate diagnoses, treatment(s), lab result(s), and other necessary health information, so the primary care physician or other practice can maintain continuity of care.

[ ] Other:

This authorization permits MALIK RHEUMATOLOGY, P.A. to disclose ONLY the information determined to be the “minimum necessary” (unless the “entire medical record” option is selected above) to the primary care physician or other medical practice. Additional information shall require another authorization.

The patient has a right to revoke this authorization in writing, except to the extent that action has been taken in reliance on this authorization or, if applicable, during a contestability period.

In order for the revocation of this authorization to be effective, MALIK RHEUMATOLOGY, P.A. must receive the revocation in writing. The revocation must include:

• The patient’s name, address, and patient number, if applicable, • The effective date of this authorization, and the recipients of the protected health information according to this authorization, • The patient’s desire to revoke this authorization, and • The date of the revocation, and the patient’s signature.

MALIK RHEUMATOLOGY, P.A. will accept written revocations of this authorization via:

[ ] Certified U.S. mail. [ ] Facsimile at this number:

ALL revocations must be sent to MALIK RHEUMATOLOGY, P.A. to the attention of the Privacy Officer, and are not effective until received by the Privacy Officer.

This authorization shall expire on After this date, MALIK RHEUMATOLOGY, P.A. can no longer use or disclose the patient’s protected health information without first obtaining a new authorization form.

I fully understand and accept the terms of this authorization.

FOR OFFICE USE ONLY Authorization added to the patient’s medical record on Authorization verified by on

Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Copyright © 2019 Malik Rheumatology, PA. All rights reserved.