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
- Patient Information
- Notice of HIPAA Acknowledgement
- Medical History
Patient Referral Form for Referring Physicians
Insurances Accepted
We are "in plan" with the following insurance companies:
- AARP
- Aetna
- APWU
- Bankers Life
- Blue Care Network
- Blue Cross Blue Shield
- Cofinity
- Golden Rule
- Great-West Healthcare
- hap HMO
- hap Medicare Advantage
- hap Preferred
- Health Alliance Plan
- HealthPlus PPO & HMO
- Humana
- Humana Medicare
- Medicare
- Medicare Advantage
- MultiPlan
- PHCS
- PriorityHealth PPO, HMO, & Medicare Advantage
- Railroad Medicare
- Total Health Care
- TRICARE
- UMR
- United Healthcare
We also participate with a few vision insurances which allows us to bill your Refraction (the test for your glasses). The charge for this procedure is in addition to your office visit which is billed through your medical policy. This test is Not covered by your medical policy. If vision insurance is something you do not carry, the charge is $45 for the test for glasses. If you have any questions, please feel free to call the office at (734) 522-9630 regarding this matter.