Patient Forms
WE ARE NOW ACCEPTING NEW PATIENTS!
As your physician, it is extremely important that all of your information is correct and up to date, in order to provide you with the best care possible.
If you are a New Patient, or coming in for your yearly annual exam, please fill out the forms below and bring them to your appointment.
- Patient Information
- Health History Form
- HIPAA Patient Consent
- Patient Consent for Treatment
- Patient Info Release to Family Member
OTHER IMPORTANT OFFICE FORMS
We value and respect our patient’s concerns or issues that may arise. Please fill out the form below and we will do everything in our power to address your complaint.
Riverside OB/GYN Medical Release Form
Consent for treatment of a minor
Insurance that we accept
- AARP
- Aetna (Commercial)
- Aetna Medicare Advantage
- Alliance Health and Life
- Beech Street PPO
- Blue Care Network
- Blue Cross Blue Shield of Michigan
- (PPO, Community Blue, MESSA, FEP, All out of state BCBS, Preferred Plus, Blue Preferred Plus, Anthem)
- Cigna PPO
- Cigna/HAP Preferred PPO
- Cofinity PPO
- Coventry PPO
- First Health PPO
- Hap Senior Plus
- Health Alliance Plan (HAP)
- HAP Preferred Choices PPO
- HAP Senior Plus
- HealthPlus PPO
- Medicaid
- Straight Medicaid, Meridian, Molina)
- Medicare
- Medicare Plus Blue
- Medicare Railroad
- Molina Medicare
- (Dual Choice, Dual Options)
- Multiplan
- Narrow Network Beaumont
- Paramount
- PHCS PPO (Private Health Care Systems)
- Priority Health (PPO, HMO, Medicare Advantage)
- Tricare East
- UMR (Beaumont)
- United Healthcare (PPO, HMO, Choice Plus)
- United Healthcare Medicare Advantage
Insurance that we do not accept
- Amerihealth (Medicare and Medicaid)
- Aetna Premier Care Network
- Blue Care Network Medicare Advantage
- Blue Cross Blue Shield EPO
- Cigna HMO
- Cofinity HMO & OSHCARE
- Coventry Care
- HAP Midwest thru Medicaid
- HAP Wayne County 4 Stars & Alliance Health & Life Country 4 Stars
- Harbor Health
- Health Plus HMO
- HPN (Blue High Performance Network through BCN)
- Humana HMO
- Humana Medicare/li>
- MEDICAID PLANS WE DO NOT TAKE
- (MI Child, Aetna Better Health, Blue Cross Complete, Total Healthcare, United Healthcare Community Plan, HAP Empowered, Priority Health)
- OSHCARE
- Paramount HMO
- PCHS HMO
- Total Healthcare (Through Employer)
- U of M Premier Network (BCN through U of M)