Patient forms

There are 5 forms to complete. Tap each tab, complete the form, and select Submit form. A ✓ appears on each tab once that form is received by our office. Use English letters in all fields.

You can download your completed forms as PDFs before or after submitting. For HIPAA and PCMH, only the signature page is sent to our office. Your download includes the full document and your completed signature page.

Your forms: 0 of 5 done

Form 1 of 5: Patient registration

Patient information

Please complete all applicable fields.

Today's date (required) Birth date (required) Last name (required) First name (required) Middle name Marital status Sex Street address (required) City (required) State (required) ZIP code (required) Home phone Cell phone Email

Emergency contact

Name (required) Relationship (required) Home phone (home or cell required) Cell phone (home or cell required)

Other information

Referred by Employer

Permission to release information

Who, besides yourself, may receive test results or other pertinent medical information on your behalf?

Name Phone number

Form 4 of 5: Financial Disclosure & Office Policy

Insurance and coverage

Please present your current insurance card and photo ID at each visit. The office submits insurance claims as a courtesy. You are responsible for providing correct insurance information, understanding your benefits, and knowing whether referrals or prior authorization are required. Not all services are covered by every plan; noncovered services are your responsibility.

Financial responsibility

You are responsible for copayments, deductibles, coinsurance, and any remaining balance after your insurance processes a claim. Copayments are due at the time of service. Prior balances must be paid before scheduled appointments. If you do not have insurance, payment for the office visit is due at the time of the visit. A $25 fee applies to checks returned for insufficient funds.

Billing and collections

Unpaid balances are billed monthly and are due within 30 days. Accounts more than 90 days overdue may be referred to a collection agency; finance charges may apply. If your account is in collection, the delinquent amount and payment for current services are due before your appointment.

Medical records

Requests for medical records or FMLA paperwork may require an upfront fee and can take 72 hours or longer to process.

No-show and cancellation policy

A $50 missed appointment fee is charged if you do not contact the office within 24 hours to cancel or reschedule. The fee must be paid before your next scheduled appointment. Unless there are extenuating circumstances, after a third no-show appointment you will receive a letter stating that you are being discharged from the practice.

By signing, I acknowledge that I have read this financial disclosure and office policy.

Acknowledgment

Patient last name (required) Patient first name (required) Date (required) Patient / legal guardian signature (required)

Form 5 of 5: Patient-Centered Medical Home (PCMH) Agreement

A patient-centered medical home is a partnership between the patient and their physician.

Being part of a patient-centered medical home, our doctor will:

Work with you to improve your health.
Review your medications at every visit and discuss any interactions or contradictions with you.
Electronically prescribe your medications to ensure they are accurate and available promptly.
Develop a personal action plan with you to address your chronic conditions.
Set goals with you and monitor your progress.
Use computer technology to monitor your progress and determine whether your health is improving.
Inform you of all test results.
Help you take control of your health by providing educational material, hosting group visits, and linking you to community programs and resources.

By choosing to participate in a patient-centered medical home, I agree to:

Make sure my doctor knows my entire medical history.
Tell my doctor all the medications I am taking.
Actively participate with my doctors in planning my care.
Keep my appointments as scheduled.
Adhere to the action plan designed by my doctors.
Consult my doctor before making my own appointment with a specialist.
Request that any other doctor I see send my report, copies of lab work, test results, and x-rays.
Know my insurance and what it covers.
Provide the office feedback on how they can improve.

Agreement

Patient last name (required) Patient first name (required) Date (required) Patient / legal guardian signature (required)

Need help? Call 248-288-9300. Submitting this form does not book or confirm an appointment. Request an appointment.

Patient forms

Your forms: 0 of 5 done

Save your completed forms

Form 1 of 5: Patient registration

Form 2 of 5: Medical history

Form 3 of 5: HIPAA Notice of Privacy Practices

Form 4 of 5: Financial Disclosure & Office Policy

Insurance and coverage

Financial responsibility

Billing and collections

Medical records

No-show and cancellation policy

Form 5 of 5: Patient-Centered Medical Home (PCMH) Agreement

Being part of a patient-centered medical home, our doctor will:

By choosing to participate in a patient-centered medical home, I agree to:

Patient forms

Your forms: 0 of 5 done

Save your completed forms

Form 1 of 5: Patient registration ✓ Done

Form 2 of 5: Medical history ✓ Done

Form 3 of 5: HIPAA Notice of Privacy Practices ✓ Done

Form 4 of 5: Financial Disclosure & Office Policy ✓ Done

Insurance and coverage

Financial responsibility

Billing and collections

Medical records

No-show and cancellation policy

Form 5 of 5: Patient-Centered Medical Home (PCMH) Agreement ✓ Done

Being part of a patient-centered medical home, our doctor will:

By choosing to participate in a patient-centered medical home, I agree to:

Form 1 of 5: Patient registration

Form 2 of 5: Medical history

Form 3 of 5: HIPAA Notice of Privacy Practices

Form 4 of 5: Financial Disclosure & Office Policy

Form 5 of 5: Patient-Centered Medical Home (PCMH) Agreement