Patient forms & resources
Download forms before your visit
These forms and documents are provided as downloadable PDFs. You may open or save them on your device, but nothing can be submitted through this website.
Questions? Call (978) 775-1428.
Referral fax: (978) 346-3000
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Common patient forms
These are commonly requested for a new-patient visit. Confirm with the office which forms you need to complete.
Patient Intake & Health History
Share your medical and surgical history, medications, allergies, and the reason for your visit.
Patient Demographics
Provide contact, insurance, emergency-contact, and other registration information.
Benefits Assignment
Review and complete the practice's assignment-of-benefits form.
Financial Policy
Review the practice's payment, insurance, and financial-responsibility policies.
As needed
Conditional, consent, and medical-record forms
Use conditional forms only when the office tells you they apply. Call if you are unsure.
Telehealth Consent
Complete this form only when the office arranges a telehealth visit and asks you to use it.
Advance Beneficiary Notice
A conditional Medicare notice. Use it only when a member of the practice team explains that it applies to your care.
Authorization to Obtain Medical Records
Authorize another organization to release records to Merrimack Thoracic & Esophageal Surgery.
Request to Amend a Medical Record
Request a correction or amendment to information in your medical record.
Policies & costs
Practice policies and billing information
Review the status shown on each document and call the office when current terms or requirements need confirmation.
No-Show & Cancellation Policy
Existing policy PDF. The notice period is under office review; call to confirm the current requirement before relying on it.
Self-Pay Office Visit Fees
Current professional fees for eligible self-pay office visits. Hospital, imaging, laboratory, pathology, anesthesia, procedure, and other-provider charges are separate.
No Surprises Act Acknowledgment
Archived federal form displaying an OMB expiration date of May 31, 2025. Do not complete or rely on this version; call the office for current information.
Surprise Billing Protections
Archived notice displaying an OMB expiration date of May 31, 2025. Do not complete or rely on this version; call the office for current information.
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Patient education resources
These guides provide general information and do not replace advice from your clinical team.
Frequently Asked Questions About Your Health Plan
Questions to ask your insurer about coverage, authorizations, networks, and out-of-pocket costs.
Lung Cancer Screening Brochure
An overview of screening and questions to discuss with your health care team.
Breathe Easy Guide
Patient education and practical support for people navigating lung cancer care.
Immunotherapy for Lung Cancer
General information about immunotherapy and topics to discuss with your oncology team.
Living With Lung Cancer
General information and support for patients living with lung cancer.
Caregiving for a Loved One With Lung Cancer
Practical information for family members and other caregivers supporting someone with lung cancer.