Forms

• Authorization to Transfer Records from Previous Office to PCC

• Authorization to Treat Minor in Absence of Parent

• Health History

• Financial Agreement

• Patient Care Medical Home Brochure

• Patient Consent for Use and Disclosure of Protected Health Information

• Patient Intake Form

• Privacy Practice Acknowledgement Form 

(Please review the Notice of Privacy Practices (HIPAA) Policy prior to signing this form)

• Vaccine Policy

In addition to the New Patient forms listed above, the following form is also required:

• Post-Partum Screening Survey

In order to expedite your visit, please review, print, and complete the appropriate forms at your leisure prior to your appointment day. Don't forget to bring the completed form to your appointment. 

• Patients Age Under 2

(If needed for daycare, please complete the Health Appraisal , Page 1 Form.)

• Patients Age 2-10

(Please complete the Health Appraisal , Page 1 Form. If you think you may also need a sports physical, then please complete the Sports Physical form.)

• Patients Age 11-18

(Please complete the Sports Physical Form.)

• Health Appraisal, Page 1

(Parents should complete the Personal section and Section 1 - Health History)

• Sports Physical

(Parents should complete the section at the top of page 1, and all of page 2 in the Health History section. During your appointment the physician will complete the Physical Examination & Medical Clearance section.)

• Authorization to Transfer Records from PCC to Other Doctor

(Authorization to transfer records from Pediatric Care Corner to another doctor or your new adult provider.)

• Authorization to Transfer Records from Previous Office to PCC

(Authorization to transfer records from another doctor to Pediatric Care Corner)

• Authorization to Treat Minor in Absence of Parent

• Patient Consent for Use and Disclosure of Protected Health Information

Payment of co-pays is expected in full during the check in process of each visit. Please be sure to know your co-pay amount. Our receptionists will inform you of your outstanding balance when you make your appointments and when you check in for your visit. You are responsible for payment of your outstanding balances which includes deductibles, co-insurances, and services not covered by insurance, at the time of service.

You are responsible for providing us with accurate insurance information at the time of your visit. This includes providing your current insurance cards and informing us of any recent changes in employment, insurance carrier, coverage, or address/phone number changes. You will also be asked to provide your driver's license at each visit. If you are unable to provide current insurance information you will be responsible for the amount of the visit, payable at the time of service; otherwise, you will have to reschedule your appointment.

It is your responsibility to know in advance of your appointment time what your insurance policy covers. Payment for any services not covered by your insurance are your responsibility. Our billing staff will process your insurance claims for you and answer any billing related questions. Please be advised that, regardless of your insurance, final responsibility for payment of our services is your obligation. If you need help in establishing a payment plan, you can contact our Billing Department at 248-926-1420.

We are pleased to accept most major credit cards and debit cards. We do charge a $35.00 fee for any returned checks due to insufficient funds.

Please review our financial agreement for a detailed description of our financial policies:

• Financial Agreement

For information about our HIPAA policy, please click here to download our HIPAA Policy.

• Acknowledgment of Receipt of Notice of Privacy Practices

• Patient Consent for Use and Disclosure of Protected Health Information

• 18-Year-Old Information Packet

• Auth to Release Healthcare Info to Parent,Caregiver

• Authorization to Transfer Records from PCC to Other Doctor

(Authorization to transfer records from Pediatric Care Corner to another doctor or your new adult provider.)

• Financial Agreement

• Patient Consent for Use and Disclosure of PHI

• Privacy Practice Acknowledgement Form