Dear Patient,

Thank you for choosing Visiting Physicians of Detroit. It is our desire to provide you with the best care available. We look forward to assisting in your recovery getting you back to your regular activities quickly and safely.

Due to the amount of time that our staff may need to spend with you at your initial appointment we ask that you arrive 15 minutes prior to your scheduled appointment time. This will allow our staff to enter all of your information into the computer and obtain any information that may still be needed. Due to the complexity of some of our patients you may experience a longer wait time. Please come prepared and we will make every effort to maintain our schedule.

At your initial appointment, our staff will take a complete history. Please complete the attached new patient packet in its entirety. If you need additional space you may use an additional sheet of paper. This will ensure the provider has a complete and accurate history. Please bring your driver’s license and insurance cards to your appointment. All Copayments and Deductibles will be collected at the time of service.

If you have any questions or concerns, please contact our office at any time for assistance.



Sincerely, Visiting Physicians of Detroit

I hereby authorize my Medical Records to be released to/from Visiting Physicians of Detroit. This information to be released is to be used only for the following authorized purpose:

¬ Planning and Management of Medical Care

¬ Payment of Services by a Third Party Payor

¬ Purposes of Litigation with Visiting Physicians of Detroit Counsel

• • I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

• • I understand that the information in my medical record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

Please list responsible parties who may receive your health information. (Spouse, mother, child, Nurse Case Manager, etc.) Please provide name and relationship below:

I have read the information provided on this release form and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

This Release of Information will remain in effect until terminated by me in writing. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

If unable to reach me:

¬ you may leave a detailed message regarding appointment reminders, test results, general messages

¬ please leave a message asking me to return your call.

It is important for you to know what your insurance policy covers. Please be aware that not all medical services are covered benefits under all insurance contracts. As your provider, please remember that our relationship is with you and not your insurance company. Your benefit coverage is a contract between you and your insurance company. If you have any questions about your insurance coverage please contact your insurance company directly.



Visiting Physicians of Detroit employs Registered Medical Coders and Certified Professional Coders to bill your insurance as a courtesy to you. Providing us with accurate information at the time of service will result in timely filing of your claims. Any changes in coverage, address, or insurance company contract information should be reported back to the office immediately.


It is your responsibility to check with your insurance company to ensure that Visiting Physicians of Detroit participates with your insurance network. If Visiting Physicians of Detroit is not in your insurance company’s network you may incur higher patient responsibility amounts.


If you do not have insurance, you will be expected to pay for your appointment in full at the time of your appointment.


In order to comply with your insurance company requirements, all deductibles and copayments are due at the time of service.


You are responsible for payment of any and all treatments that may not be covered by your insurance.


Failure to pay any amount due, including past due balances, will result in your appointment being rescheduled.


Patients will be charged a fee of $50.00 per check for checks returned to our office for non- sufficient funds.

It is your responsibility to provide Visiting Physicians of Detroit with ALL accurate, complete and up to date information regarding any and all insurance policies that you have in place prior to each visit. Failure to provide all of this information in its entirety will result in the patient being personally responsible for any and all charges not covered or paid for by an insurance company. Even if Visiting Physicians of Detroit participates with an insurance policy that you have at the time of service/visit, failure to provide this information will mean that Visiting Physicians of Detroit is not bound by any contractual agreement with your insurance carrier and the patient will be fully responsible for all charges.

Patients will be charged a fee of $50.00 for failure to cancel their appointment within 24 hours prior to the appointment and/or not showing for their appointment. Patients may be discharged from the practice at the provider’s discretion.

If your account is over 120 days past due, your account will be referred to our outside collection agency. This may include listing with the credit bureau. Your account will be reviewed for possible discharge from care.

Patients agree that if they have a credit balance after paying for a service, Visiting Physicians of Detroit can apply this credit to any outstanding balance on their account. Patients will be refunded any amounts paid in excess upon request after all outstanding amounts have been credited.

In all instances, our office will work with patients having difficulties paying for their care. We understand that extenuating circumstances occur with injuries and accidents and we would like to help you navigate the issues that arise. If you would like to speak with someone regarding payments, please contact our Patient Accounts Department.

I have read and understand the above Financial Policy. I hereby authorize Visiting Physicians of Detroit to file claims on my behalf and for payment of insurance benefits be made directly to Visiting Physicians of Detroit for those services.

PLEASE COMPLETE THE FOLLOWING USING YOUR MOST RECENT EMPLOYER – EVEN IF YOU ARE NOT CURRENTLY WORKING

I give my consent and authorize medical treatment as deemed necessary and appropriate by the physicians of VISITING PHYSICIANS OF DETROIT, PLLC and their employees participating in my care.


I authorize VISITING PHYSICIANS OF DETROIT, PLLC to release pertinent information to my health insurance companies that is required during my examination or treatment. I also give my consent and authorize payment of all insurance benefits, including Medicare and Medicaid payments, be sent directly to VISITING PHYSICIANS OF DETROIT, PLLC. I understand that I am solely responsible for any medical or surgical changes incurred during my treatment that are rejected by my insurance company or are considered co-pays or deductibles as applicable.


I am aware that the practice of medicine and surgery is not an exact science and no guarantees have been made to me with respect to the results of such diagnostics or treatment.


I also authorize VISITING PHYSICIAN OF DETROIT, PLLC to contact me via phone or mail, including leaving messages, sending out letters, about my care provided it assists the practice in carrying out necessary treatments for me, or as required to ensure payment or other timely management of health-related benefits for myself.


A drug screen (blood or urine) sample may be obtained with verbal consent for purposes of compliance with medication regimens or when misuse is suspected, or signs or symptoms of toxicity exist.


I understand that samples of body fluids and/or tissues may be withdrawn from me during routine diagnostic procedures. I authorize VISITING PHYSICIANS OF DETROIT, PLLC Services to dispose of the bodily fluids.


I consent in being automatically enrolled in the Chronic Care Management Program that will give me 24/7 access to my provider, in return, it will allow my advanced practitioner and their designees to perform a CCM on my behalf. I understand that VISITING PHYSICIANS OF DETROIT, PLLC will bill my insurance for this service, and that I am responsible for any copayment or deductible. I understand that I can revoke this permission at any time by notifying VISITING PHYSICIANS OF DETROIT, PLLC in writing.


I have been informed that registered nurses will be utilized to provide care coordination and monthly telephone case management services to educate, inform and develop yearly care planning to maintain, improve and/or assist with transitional, behavioral health, and chronic care management.


I understand that I may revoke this consent in writing, as permitted by law, except to the extent that the practice has already made disclosures or provided treatment in reliance upon my prior consent. If I refuse to sign this consent, I understand that VISITING PHYSICIANS OF DETROIT, PLLC has the right to decline to provide services and treatment to me.

As a participant in treatment for pain management, I freely and voluntarily agree to accept this treatment contract as follows:


1. I agree not to sell or give any of my medication to another person. I understand that it is illegal and could result in being discharged.


2. I agree that my prescription can only be given at my regular doctor visits. If I miss a visit/or cancel my appointment I cannot get my medication/prescription until the next doctor visit. (Unless a documented emergency occurs).


3. I understand that narcotic medications will NOT be called in. I understand the DR will NOT refill any narcotic medication without a visit. NO early refills permitted.


4. I agree NOT to get ANY other narcotic pain medicine from another doctor, unless an Emergency. I agree that ONLY the DR will prescribe my pain medicine. If narcotic pain medicine is prescribed in my name (after I sign this agreement) I could be discharged.


5. I agree that any rude, inappropriate, or threatening behavior to the doctor, his staff, or the pharmacy may result in being discharged.


6. I agree that the medication I receive is my responsibility. I agree to keep it in a safe, secure place. I agree that medication may not be replaced if lost or stolen.


7. I agree to take my medication as instructed and not to change (increase or decrease) the way I take my medication without first asking my doctor.


8. I agree NOT to take any benzodiazepam medications (Valium, Klonipin, Xanax, etc.) unless
authorized/prescribed by the DR or under emergency conditions at a hospital.
9. I understand that medication alone is not sufficient treatment for my condition. Other treatments, including Physical Therapy or even possible intervention/injections, and/or surgery may be recommended as part of my treatment.

10. I agree not to take any other narcotics/*pain medicine, cocaine, or addictive/illegal substance(s). *Unless a hospital emergency, and then I will notify Traveling Doctor’s office with the hospital information.

11. I agree to provide random *urine samples. I understand that Michigan Guidelines for prescribing narcotic pain medicine include urine monitoring. If I refuse to provide urine for this purpose, the DR is NOT required to prescribe my pain medicine AND I may be discharged. *Dialysis patients agree to provide blood samples for monitoring.

12. I agree NOT TO TAKE SOMA; I understand the DR DOES NOT prescribe XANAX, due to its high abuse potential. The DR may prescribe a similar medication (Klonipin, Valium or other safer “cousins” to Xanax) if needed for short term severe anxiety. No cough syrup with Codeine will be prescribed, especially with pain medicine.

13. I agree if I use marijuana, Visiting Physicians of Detroit is not responsible for any interaction with my other medications.

14. I understand if I make suicidal statements, Visiting Physicians of Detroit is legally bound to call 911.

15. I understand that violations of the above may be grounds for termination of treatment.

I have answered all of the questions in full and to the best of my ability. I certify the information I have provided is true. I do understand any false information or information left out could affect my medical care and rehabilitation. I promise to notify the office of Visiting Physicians of Detroit immediately should there be any changes or new information. If female, I am aware that I may undergo procedures that could be potentially harmful to an unborn baby. If female, I agree to notify the office of Visiting Physicians of Detroit immediately if I suspect I may be pregnant. I hereby authorize and consent Visiting Physicians of Detroit to furnish the requested treatment and/or diagnostic services.