Patient Information and Forms

Medical History Form

Print this form and complete it by hand or fill the form using Adobe Acrobat. Print a hard copy and bring it to your appointment to save time filling it out at our office.

Privacy Policy

This notice describes how Health Information about you may be used and how you can get access to this information. Please review it carefully. The Privacy of your Health Information is important to us.

Financial Policy Acknowledgement

Please take a moment to download and review our financial policy. You can bring your signed form to your next appointment.

New Patient Information Forms (Combined)

This document contains all three forms (Medical History, Financial Policy, and Privacy Policy)

New Patients Please Bring

  • Your completed PATIENT INFORMATION FORM and MEDICAL HISTORY FORM available here
  • Referral , if required, from your doctor
  • Authorization from your carrier if workman’s comp or an auto accident
  • Your insurance card
  • Results of any recent tests pertaining to your condition including EMG studies.
  • X-rays, CT scans, or MRI films. We would like to see the actual imaging study (films or a CD) instead of just a typed report. If your x-rays were taken at Beaumont, St. Joseph’s, or Crittenton we can usually view the images online from our office. If you were seen at an urgent care center, we likely DO NOT have access to your x-rays and you should bring them with you.


If your insurance plan requires a referral from your primary care physician, you must have this before treatment is given. Please have this referral before your appointment to avoid frustration and potential delays in care

Workers Compensation

Worker’s Compensation patients must have proper authorization before being seen by a physician. Surgery, if needed, will not be scheduled until approval is given.


Here’s a handy link to a PDF Document Reader to use with our forms if your computer cannot open them otherwise.


  • Aetna U.S. Healthcare – EPO, POS, PPO
  • Alliance Health & Life (HAP) – EPO, PPO
  • Beaumont Employee Health Plan – PPO
  • Blue Care Network – HMO
  • Blue Choice – PPO
  • Blue Cross/Blue Shield
  • Blue Preferred Community Blue (Trust) – PPO
  • Blue Preferred Plus
  • Cigna HAP Preferred – PPO, POS, EPO
  • Cofinity/PPOM
  • HAP Preferred Health Plan (PHP) – EPO, PPO
  • Health Alliance Plan (HAP) – POS
  • Health Plus of Michigan – POS
  • Health Plus of Michigan – PPO
  • Humana – PPO
  • Jones Lang LaSalle at Beaumont – PPO
  • Medicare
  • Medicare-Aetna Medicare Plan – PPO
  • Medicare-Alliance (Alliance Health & Life) – PPO
  • Medicare-Blue Care Network Advantage – HMO
  • Medicare-HAP Senior Plus – HMO
  • Medicare-Plus Blue – PPO
  • Priority Health – HMO
  • Priority Health – PPO
  • TriCare Standard (formerly Champus)
  • United Health Care – EPO, PPO, POS
  • United Physicians Health Insurance Program
  • Worker’s Compensation

Plus others … please call to learn more