Patient filling out form

Patient Information

Patient Forms

New Patient Form

We prefer that you complete our online form before your appointment.

If you are unable to complete your form online, the PDF form can be downloaded. You may email the form, or fax the form to (248)-651-3366 . Each family member will need to fill out their own new patient form.

The day of your appointment please bring in your identification card, and insurance card for copies to be made for each individual patient chart. Your office visit copay will be due on the same day as your visit. Please contact you insurance company to find out how much your copay is, if you do not already know.

Medical Release Form

If you would like your medical forms released to or from another office, please fill this form out completely, sign it, and fax it to our office at (248)-651-3366.


Please read our HIPAA privacy notice.


If your insurance is not listed below, please call us at 248-651-9500.

We Participate With:

All Plans – PPO, EPO, POS, HMO*, Medicare PPO, Meritain, Open Choice PPO, Choice POS II, Managed Choice POS, Elect Choice EPO, Select, Open Access, Premier Care Network

Blue Cross Blue Shield of Michigan
All Plans – PPO, EPO, BCN*, BCN Advantage, Blue Choice, Blue Preferred Plus, Federal, Out of State PPO, Medicare Plus Blue and Medicare Plus Blue PPO, U of M Premier Care Tier 1

Beech Street Network – (Concertra Network)

Beaumont Employee Health Plan

ChampVa or Tricare
Prime* referral needed, or out of network copay/deductible will be applied

All Plans – PPO, EPO, HMO*, POS, GreatWest,- PPO & POS, Open Access Plus, OA Plus, ChoiceFund OA Plus, Choice Fund PPO

Cofinity Network

An out Out of Network deductible will be applied

First Health Network (Coventry)

Great West

HAP (Health Alliance Plan or Alliance Health Plan)
HMO, PPO, POS, EPA, Alliance Medicare PPO, Senior Plus HMO

Humana Choice Care Network
PPO & Medicare, Humana Medicare-Gold Plus HMO

McLaren Health Plan
Health Advantage PPO, Medicare Advantage.

Medicare & Railroad Medicare

Meridian Medicare

Multiplan Network
(Private Health Care System)

Priority Health
PPO & HMO, Medicare Advantage, POS, EPO, Beaumont Health Network – Narrow Network

Smart Health
We are in network with Crittenton Hospital only. Trinity Health Network & St. John’s Providence we are out of network, we can bill under Tier 2 benefits which has a deductible.

Total Health Care
PPO through Cofinty, POS - has a Separate deductble for out network

United Health Care
All Plans – PPO, EPO, HMO*, POS, Medicare Advantage PPO, Choice & Choice Plus, Select & Select Plus, United Health One - Golden Rule, Oxford, Navigate & Compass (Navigate, Navigate Plus HMO* – needs a referral.)

*Requires a referral from the Primary Care Physician

We Do Not Participate With:

Aetna Premier Care Network & Aetna Better Health Medicaid

Blue Cross Blue Shield of Michigan Complete Medicaid

Henry Ford, Genesys, Access, & Wayne County 4 Star

HealthPlus of Michigan Medicaid

Humana HMO

McLaren Health Plan

Midwest Medicaid

Meridian Medicaid

Molina Medicaid

Priority Health
Medicaid, Narrow Network of: St. John Providence, St Joseph, Spectrum, Bronson, West Michigan Partners

Total Health Care
We do not accept HMO or Medicaid, PCP will be listed on card

United Health Care
Medicaid (Community Health or Healthy Michigan)