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.

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*

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

Beech Street Network – (Concertra Network)

Beaumont Employee Health Plan

Champus or Tricare
Prime referral needed or out of network copay/deductible will be applied

Cigna
All Plans – PPO, EPO, HMO*, POS

Cofinity Network
PPOM

DMC
An out Out of Network deductible will be applied

First Health Network (Coventry)

Great West
PPO & POS

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

HealthPlus of Michigan
PPO, Commerical HMO*, Commerical POS (no deduct. With referral), Medicare Advantage HMO* (PPO will be on card, if nothing is mention it is an HMO*)

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

McLaren Health Plan
Health Advantage PPO, Medicare Advantage, (POS - out of network deductible with be applied)

Medicare & Railroad Medicare

Multiplan Network

PHCS Network
(Private Health Care System)

Priority Health
PPO & HMO, Medicare Advantage, POS, EPO

Smart Health
We are in network with Crittenton Hopsital 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

United Health Care
All Plans – PPO, EPO, HMO*, POS, Medicare Advantage PPO, Navigate & Compass (Navigate, Navigate Plus HMO* – needs a referral.)

*HMO 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

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

HealthPlus of Michigan Medicaid

Humana HMO

McLaren Health Plan
Medicaid

Midwest Medicaid

Meridian Medicaid

Molina Medicaid

Priority Health
Medicaid, Narrow Network of: St. John Providence, Beaumont Health Network, 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)