Patient Information
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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.
HIPAA
Please read our HIPAA privacy notice.
Insurance
If your insurance is not listed below, please call us at 248-651-9500.
We Participate With:
Aetna
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
Cigna
All Plans – PPO, EPO, HMO*, POS, GreatWest,- PPO & POS, Open Access Plus, OA Plus, ChoiceFund OA Plus, Choice Fund PPO
Cofinity Network (PPOM)
Coventry – Aetna
First Health Network
Great West
PPO & POS
HAP (Health Alliance Plan or Alliance Health Plan)
HMO, PPO, POS, EPA, Alliance Medicare PPO, Senior Plus HMO, Primary Choice Medicare
Humana Choice Care Network
PPO & Medicare, Humana POS – Cofinity
Humana Medicare-Gold Plus HMO (10/1/19 no referrals)
McLaren Health Plan
Health Advantage PPO
Medicare & Railroad Medicare
Multiplan Network & PHCS Network
(Private Health Care System) (Beech Street)
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, United Health One - Golden
Rule, Oxford, Navigate EPO, POS, Navigate Plus HMO*,
Core Choice Plus, Core EPO & HMO*, Dept of Veterans
Affairs, Select EPO, Select Plus POS & HMO*, Indemnity
*Requires a referral from the Primary Care Physician
WE DO NOT PARTICIPATE WITH:
Aetna Premier Care Network & Aetna Better Health Medicaid
AARP Medicare Complete HMO
Blue Cross Blue Shield of Michigan Complete Medicaid
BCN Advantage Healthy Saver/ Healthy Value & Connected Care Narrow Network *Can be seen only with a referral
DMC
An Out of Network deductible will be applied
HAP
Henry Ford, Genesys, Access, & Wayne County 4 Star
HealthPlus of Michigan Medicaid
Humana HMO
McLaren Health Plan
Medicaid & Medicare Advantage
Midwest 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)
WellCare (Meridian)
Medicaid or Medicare/Medicaid Complete, Meridian Choice HMO, Merdian Care Extra HMO w/ Medicaid