Patient Center

Patient Forms

Please print and complete the forms included in the packet below and bring them with you to your appointment.

• HIPAA Privacy Policy - Please Print for Your Records
• New Patient Packet

If you need an individual form, please choose one below.

• HIPAA Privacy Policy - Please Print for Your Records
• Medical History
• Patient Information
• Notice of HIPAA Acknowledgement

Insurances Accepted

We are "in plan" with the following insurance companies:

• AARP
• Aetna
• APWU
• Bankers Life
• Blue Cross Blue Shield - Blue Care Network
• Cigna Healthcare
• Cofinity
• hap HMO
• hap Medicare Advantage
• hap Preferred
• Health Alliance Plan
• Humana
• Humana Medicare
• Medicare
• Medicare Advantage
• MultiPlan
• PriorityHealth PPO, HMO, & Medicare Advantage
• Railroad Medicare
• Total Health Care
• TRICARE
• UMR
• United Healthcare

The refraction portion of your medical examination is not covered by your medical policy. The refraction is the test performed to determine your eye glass prescription. The charge for this test is $45. If you have any questions, please feel free to call the office at (734) 522-9630 regarding this matter.