Patient Demographics

I hereby Authorize Avenue Health and its affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and healthcare services provided to me and which identifies my name, address, social security number, member ID number for the purpose of helping me to resolve claims and health benefit coverage issues. 

I understand that any personal health information or other information released to the person or organization above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. 

I understand that I have the right to revoke this authorization by providing written notice to. However this authorization may not be revoked if its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have the right to have a copy of this authorization.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services. 

I have been advised of this Privacy Practices, Release of Billing Information Policy, Assignment of  Benefits Policy and grant Avenue Health Medication Authorization Authority. 

If applicable, Legal Representatives may sign below:

By signing this form, I represent that I am a legal representative of the member identified above and will provide proof (e.g., Power of Attorney, living will, guardianship papers, etc. that I am legally authorized to act on the Member's behalf with respect to this authorization form.

Please help us to accommodate your wishes regarding how we communicate your health care by completing and signing this form. The following individuals are given permission to receive verbal information as indicated: Please note the below named individuals may not access, request, or receive copies of your medical records without an Authorization for Release of Medical Records signed by you.

Policies and Limitations on Alternate Means of Communication:

We are required to accommodate "reasonable" requests for communicating with you by alternate means. We may deny the request if we determine that is unreasonable. 

You agree that the security and confidentiality of the confidential information sent via alternate method is your responsibility alone, and neither the physician or the practice is responsible for any inadvertent disclosures that may occur as a result of fulfilling the request.

I authorize Avenue Health to access any and/or all external databases available to

health care providers in the state of Michigan, including Health Information Exchanges

(HIE's) and/or interoperability systems which may contain my personal health

information, on a frequency to be determined by my provider. I understand and

acknowledge that these external databases will include but not limited to, information

reflecting prescription medication filled/ordered/or used by me, which will be used to

verify current medications, coordinate care, and prevent drug interactions. This

information will become a part of my permanent health record at Avenue Health.

 

By signing this form below, I consent to the above information.

The service you are going to receive today (or at the time of your appointment) may not be covered by your insurance company. What this means to you is that you will be responsible for payment of this service in full. We will bill your insurance but there is no guarantee of payment and in the case they deny your service you will be responsible to pay Avenue Health and its Affiliates the full amount of the services provided.

There is no guarantee of benefits. Should you choose to be seen after this has been explained you will need to be aware that any service not paid by your insurance company will be your responsibility to pay.

The above policy has been explained to me and with my signature below I agree to the terms and I fully understand I will be responsible for any balances that may occur based on the lack of coverage/terms of my

At Avenue Health our goal is to assist our patients with prescription requests in an efficient manner. In order to process your requests as quickly as possible, please see the details of our prescription policy.

• Prescription refills require close monitoring by your physician, nurse practitioner, or physician assistant to ensure the safe continuation of the appropriate dose, frequency and term of that medication. Your provider will prescribe the appropriate number of prescription refills to last you until your next scheduled appointment.

• It is the patient's responsibility to schedule your next appointment in advance and with adequate time to receive a prescription refill.

• As prescriptions are prescribed with the amount of refills needed until the next appointment, almost all requests for prescription refills between regularly scheduled appointments will require an appointment in the office or a fee may be charged towards your account. The clinician will review the request from the pharmacy, as well as the patient's medical record, to determine appointment needs. The patient will be contacted by the staff to schedule such an appointment, if necessary.

• Patients requesting new prescriptions or antibiotics must be seen for an appointment by a clinician. They are not prescribed over the phone.

• Pre-authorization for medications may take 7-10 business days. For any updates on prior authorization approvals or denials, you must reach out to the pharmacy in which the prescription was sent to.

• As of January 1st, 2023, LARA (Licensing and Regulatory Affairs) is requiring all prescriptions, controlled and non-controlled, be submitted electronically.

By signing below I understand, agree and accept the policy listed above. Failure to comply may be subject to immediate termination of prescriptive medications.

Description:

“No Show” shall mean any patient who fails to arrive for a scheduled appointment.

“Same Day Cancellation” shall mean any patient who cancels an appointment less than 24 business hours before their scheduled appointment.

“Late Arrival” shall mean any patient who arrives at the clinic 10 minutes after the arrival time of their scheduled appointment. 

POLICY:

• Effective March 25th, 2024, any patient that is a late arrival will need to reschedule their appointment and be charged a fee. (See fee chart below)
  
  
• Effective March 25th, 2024 any New or established patient who No Shows, cancels/reschedules, or is a late arrival to an appointment and has not contacted our office at least 24 business hours notice will be considered a “No Show” and charged a fee. (See fee chart below)
  
  
• Any established patient who No Shows, cancels/reschedules, or is a late arrival to an appointment and has not contacted our office at least 24 hours notice a second time will be charged another fee. (See fee chart below)
  
  
• Any established patient who No Shows, cancels/reschedules, or is a late arrival to an appointment and has not contacted our office at least 24 hours notice a third time you may be discharged from the practice.

Appointment Type	Fee Expense
Annual Wellness, Medicare Wellness, Well Child	$150
New Patient	$100
Follow Up/Established Patient	$75

The fee will not be charged to the insurance company and will be the patient's responsibility. The fee will be due at the time of the patient's next appointment. 

As a courtesy, we implemented an automated system to send appointment reminders via email, text, and phone call. If you do not receive any of these reminders, the above policy will still remain in effect. 

We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our office and we may be able to waive the fee. 

Over the last 2 weeks, how often have you been bothered by any of the following problems?

 

Over the last two weeks, how often have you been bothered by the following problems?

 

Once a year, all of our patients are asked to complete this form because alcohol and affect your health as well as medications you may take. Please help provide with the best medical care by answering the questions below.

Note: if you selected "never cigarette smoker/never used smokeless tobacco" you do not have to complete this form.

Comprehensive and Integrated Health Care

Our patient centered medical home is health care focused on you, the patient. It is a partnership between you and your provider. Your provider leads a team of health care professionals committed to improving your overall health and to helping you reach your personal health goals. 

The patient centered medical home focuses on connecting the dots of coordinated care for each patient. Your health team may consist of your primary care provider, nurses, specialty physicians, pharmacists, dietitians, care coordinators and others depending on your needs. For example, do you want to quit smoking? Better control your diabetes or asthma? Lose weight? Manage your stress? Your medical home provider will put the right team in place for you. 

The Goals of a Patient Centered Medical Home (PCMH) include: 

• A discussion with your provider regarding your health care goals. 
• Asking for your input in planning your care and designing a plan which you can follow. 
• Exploring methods to appropriately care for you, and ways to help you care for yourself. 
• A reminder when appointments or tests are due so that you may receive the highest quality of care. 
• Provide access to medical care 24 hours a day, 7 days a week. 

The Patient Centered Medical Home concept includes an agreement between the provider and the patient that acknowledges the role of each in a total health care program. We will always respect you as an individual without discrimination, including your privacy and confidentiality. We will remain committed to providing the highest quality of care and professionalism.

Care Coordination 

If you are hospitalized, following up with your Primary Care Provider is essential to your recovery and minimizes possible complications. You should schedule an appointment with your Primary Care Provider within 7 days after discharge. Care Management Services are available to assist you with transportation needs, education, or other concerns. For more information or to access services; please contact our care coordinators at (844) 368-1817.

Emergencies 

Regardless of the time of day or night, if medical attention is needed please contact our office for medical advice, emergency care, and/or guidance to our preferred after-hours care facility.  Call 911 or go directly to the nearest emergency room if you are having any of the following: 

• Chest pain 
• Extreme shortness of breath 
• Head injury or trauma 
• Seizures 
• Pregnancy complications
• Signs of a stroke (numbness, paralysis, slurred speech)
• Poisoning 
• Complicated fracture
• Heavy bleeding that does not stop in 10 minutes 
• Severe burns 
• Homicidal feelings 
• Suicidal feeling

As our patient, we encourage you to: 

• Call your provider FIRST with all medical problems, unless it is a medical emergency. 
• Ask questions, share feelings, and be part of the care process. 
• Be honest about your medical history, symptoms, and other health information. 
• Tell your provider about any changes in your health and well-being. 
• Take all your prescribed medications and follow your provider’s advice. 
• Make healthy decisions about your daily habits and lifestyle, for example, healthy eating. 
• Prepare for and keep scheduled visits or reschedule visits in advance. 
• Create goals for your health.

Staff and providers in this office agree to: 

• Explain disease, treatments and results in words you can understand. 
• Listen to your feelings and questions to aid in informed decision making. 
• Keep treatments, discussions, and records private. 
• Provide 24-hour access to medical care providers. 
• Offer same day appointments whenever possible. 
• Provide clear instructions for your health care needs when the office is not open. 
• Care for you through evidence-based medicine and best practice recommendations. 
• Provide timely follow-up after hospital stay 
• Refer you to trusted specialists when additional care is suggested.

Test Results 

All patients will be notified by mail and/or phone within 48 hours after the ordering provider reviews test results. 

To schedule an appointment please call: 
Avenue Health (517) 618-9507
Monday: 9AM-5PM 
Tuesday: 9AM-5PM
Wednesday: 9AM-5PM
Thursday: 9AM-5PM
Friday: 9AM-12PM

Insurance 

We participate in many health plans. Some plans offer more choices. We encourage you to become familiar with your health plan coverage.

I havereceived the Patient Centered Medical Home brochure describing this model of care, what I can expect from my physician, and what is expected of me. My physician has also discused the detailed of Patient Centered Medical Home with me and has answered any of my questions.