PIIM - Internal Medicine primary care physician practice...Email us with Changes

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hPrivacy Notice

How we use and disclose your private medical information...

Click here to read our HIPAA Privacy Notice

Note: We are currently working on making this section of the site secure, however at this time the information submitted on this form is not secure. It is possible that others may be able to view this information.

Change your name, address, phone number, or insurance info online!

Please submit a new form for each additional patient or account number. Thank you! You may also contact us by telephone: 734-622-9697.

Fields marked with an asterisk * are required in order to process your information.

* Date of requested change:
* Patient Name:
* Date of Birth:
Last 4 digits of SSN:
Primary Care Physician:
PIIM Account Number (5-7 digits):
* Current Email Address:
Name Change:
Address Change:

Home Phone Change:
Work Phone Change:
Emergency Contact Change:

Insurance Changes

Insurance Company:

Claims Address:

Insurance Phone Number:

Policy Number:

Group Number:

Subscriber Name:

Subscriber DOB:

Subscriber Employer Name:

Is this your primary coverage?:

Yes No

If no, please explain:

Co-pay for office visits?:

Note: * indicates required fields.

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