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hPrivacy Notice

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

Click here to read our HIPAA Privacy Notice
 

We are pleased that you have chosen Partners In Internal Medicine (PIIM) to be your Primary Care Providers. In order to streamline your next visit, you may want to print off the applicable forms below.

If you have any questions regarding any of the forms, please ask the front office receptionist to assist you when you arrive for your appointment.

We would like to ask that you bring any medications you are currently taking so that we can have a definite idea of your medication name, dosage and refill needs. Your regular pharmacy name and phone number is also requested for our records.


Welcome Letter This form contains the PIIM welcome letter.

Physical Examinations Important information for patients regarding physical examinations.

Participating Insurance's This form contains a list of participating insurance's.

Guide to Your Health This document provides general information pertaining to your health and fitness.

Patient Personal
History
This form contains a "Patient Personal History" questionnaire that will provide us with your complete family history.

Financial Policy & Patient Responsibility Notice This form is our company financial policy, which explains financial payment expectations and obligations as well as payment options and responsibilities.

Release Authorization Form This form is used for you to allow PIIM to release your medical information to another doctor, organization, etc.

Questions for Today's Visit This form is the "Questions for Today's Visit" form, which is generally given to patients when checking in. It assists our patients to remember questions/concerns as well as medications they are currently taking.

Map to PIIM This is a map with directions to our offices.

Privacy Notice PIIM's Notice of Privacy Practice's.

Acknowledgment of Receipt of Privacy Notice This form is to acknowledge that you have received PIIM's Notice of Privacy Practice's. (Privacy Notice)

 
Economic Hardship Request Form This form is for patients needing consideration when facing financial hardships.

   
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Practice Information and other services:

We are committed to providing personalized patient care and strive to fulfill our commitment to better serve our patients health care needs. Therefore, we offer a unique service of trained representatives, so patients understand the requirements, cost differences and benefits of their managed care health plan. We have Managed Care Service Representatives conveniently located in each of our office locations ready to serve you in simplifying your efforts to meet all of your managed care insurance needs. We have enclosed a Managed Care Brochure, which provides specific information explaining these services.

For your convenience, we have a list of participating insurance providers. If you do not carry one of the participating insurance's, please reference the Partners in Internal Medicine Financial Policy.

We also would like to advise you that our fees are based on the comprehensiveness of your visit. Fees are most often broken into different categories and payment ranges such as New Patient ($68 - $222), Physical Examination ($146 - $216), and Established Patient ($36 - $181) visits. If any tests or procedures are ordered, there may be additional charges. St. Joseph Mercy Hospital or the preferred laboratory designated by your insurance company will bill most lab work performed.

Please note that pay arrangements are always available regardless of type of insurance. If you have additional questions or need to set up payment arrangements, please contact our Billing Service Representatives (734) 622-9697.

We look forward meeting your health care needs.


Your Health Care Partners

PIIM

 
 



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