New Patient Information
We are honored that you are considering us to care for you or a loved one. Call our office to find out if we have coverage in your area and if you or your loved one qualifies for our home physician service,
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Release of Information: This allows us to request information from previous doctors/hospitals and also to release our information to other health care providers involved in your care. If you have any concerns signing the form, you can wait until the visit to go over it.
Patient Intake Form: You do not need to fill out this form if you already gave all the information to our office over the phone. Please review it to make sure all the information was given.
Medical History Form: The more accurate information we receive the better we are able to care for you. Please fill this out and fax back to the office as soon as possible so the doctor can review it before the visit.
Consent forTreatment/Acknowledgement of Receipt of Privacy Notice/Assignment of Benefits / Authorization to Disclose Medical Information for Payment / Payment Agreement / Authorization to Leave Message: This form has one place on the second page and two places on the last page for you to sign.
Northview Medical House Calls accepts all of the following insurances. If you are not sure whether you are insured by one of these plans, please give us a call.
- Blue Cross Blue Shield of Michigan
- United Healthcare Community Plan
- Humana (only if patient has house call services in contract)
Instruction Sheet: This form informs you how to fill out the rest of the new patient packet in a complete and through fashion.