Welcome to Dr.

Heinlens Health Care Clinic

806 N State Street, Stanton, MI 48888
(989)283-2595
Welcome to our clinic! On July 11th, 2016 our clinic will open to patient care.
We will be open starting June 27th to start the transfer and registration
process. We will be open 8 am to 5 pm M-F except on July 4th and July 5th.
Please plan on coming to the office to get your paperwork during those times
or we can e-mail it to you upon your request. At this time Molina is one of the
only insurances we are not participating with. If you have Molina, we will not
be able to care for you unfortunately. For a complete list of insurances we will
be taking please call the clinic when we are open.
General rules and guidelines:
1. You must call for all refill requests. We will not accept requests from
pharmacies due to inadvertent mistakes being made. You will be
expected to tell us the name, dose, and how you take it. You must
also verify the pharmacy you wish this to go to.
2. There will be a $30 charge if you miss an appointment unless there
was an emergency. We request that you call the office if you will
miss your appointment at least 24 hour in advance if possible. If you
are late for your scheduled appointment by 10 minutes or more,
your appointment may be cancelled per provider discretion. You
may receive a $30 no show fee which your insurance will not pay
for. This will be your responsibility to pay. We will do our best to stay
on time and we ask that you do the same for us.
3. Any forms brought in will have a $10 charge for us to fill it out for
you unless we fill it out at a scheduled appointment.
4. Please refrain from wearing perfume, cologne, or other products
with strong smells due to allergy problems with the staff and other
patients.
We look forward to seeing you in the clinic!
Lene Heinlen, DO
Seaman FNP

Andrea Kemler-Spencer FNP

Aimee

I have read the above general rules and guidelines.

________________________________________________________________________
Patient or Guardian Signature

Date

Please complete these forms and mail to:

Dr. Heinlens Health Care Clinic
PO Box 477
Stanton, MI 48888
Please use the PO Box listed above to assure
we get the forms on a timely basis. Please
call the office during the times noted below
to schedule an appointment.
May also drop them off at the office June 27th
to July 8th. We will be open Monday thru
Friday 8 am to 5 pm. We will be closed for the
holiday on July 4th and July 5th.

Consent for Release of Medical Information

Patient Name:_______________________

DOB:____________

Address:___________________________________________________
Release From:_________________________
_________________________
_________________________
Release To: Dr. Heinlens Health Care Clinic
806 N State Street

Phone: (989)283-2595

PO Box 477
Stanton, MI 48888
Records Requested:
____X-ray Report(s)
____Diagnostic Studies
____Consultation(s)

____Laboratory Reports
____Progress Notes
____All

____Other: _______________________________
Dates of records requested:
From: _____________

To: _________________

Records shall be used for: _X___Continuation of care

This consent is valid for 90 days from the date signed.
I hereby authorize ________________________to deliver a copy of my records to Dr.
Heinlens Health Care Clinic as stated above. I, the patient or patients
representative have the legal right to inspect, copy and request delivery as
specified of this Protected Health Information within the next 30 days in accordance
with Public Law 104-191 (HIPAA-1996). I accept the responsibility for any fees that
may be associated with this request.
Patient Signature:_____________________ Date:_________
Patients Legal Representative:___________________ Date:________
This request is confidential and intended for the addressee only. Disclosure, copying, altering
or communication of this message if you are not the addressee is prohibited by law.

Patient Registration
Legal Name:___________________________ Birthdate:________
Last, First MI
Address:________________________________________________________
City:____________________ State:__________ Zip: ______________
Daytime Phone #:__________________Alt.Phone#:___________________
E-Mail: ______________________________
Social Security #:_______________
Are you: Married Single Divorced Widowed
Primary Language:____________________________ Race: _______________
Ethnic Background: Hispanic/Latino or Not Hispanic/Latino
In case of an emergency, contact:______________________________
Relationship:_________________ Phone:_____________________
Employer:___________________________ Phone: ______________

Primary Insurance:__________________________________
Subscriber:______________________ Birth Date:__________
Policy Number:_____________ Group Number: __________

Secondary Insurance:__________________________________
Subscriber:______________________ Birth Date:__________
Policy Number:_____________ Group Number: __________
I AUTHORIZE Dr. Heinlens Health Care Clinc TO BILL MY INSURANCE CARRIER AND
IF NECESSARY TO RELEASE ANY MEDICAL OR PERSONAL INFORMATION REQUIRED
TO PROCESS THE INSURANCE CLAIM ON MY BEHALF.
Signature:_________________________________
Patient or Legal Guardian Signature
Printed Name: _____________________________

Date:______________

Patient Health Information

Patient Name: ________________________ DOB: _____________
Allergies and the reaction you had:
_________________________________________________________
_________________________________________________________
List ALL MEDICATIONS you take, including vitamins and holistic.
Medication Name

Dose

How Often

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Please attach a complete list of medication if you need more room.
If you have a list of your immunization history, please attach a copy. If you do not
have one, we will get the history from the Michigan Care Improvement Registry
(MCIR) website.
SOCIAL HISTORY:
Recreational Drug Use: No Yes If yes, which ones:________
Smoking: Currently Past Never Packs/day:________________
Alcohol: Currently Past Never Drinks/day:_______________
Please put the date of your last test. If you are not sure of the date, leave it blank. If
it does not apply to you put NA.
HgbA1C (diabetic lab)________ Cholesterol:________
Pap:________ Mammogram:________ Bone Density:________
Prostate Cancer Screen:________ Colonoscopy:________
Were any of those tests abnormal? ______________________
Is Mom still living? _______ If deceased, what age and what was

the cause of death? _____________________________________

Is Dad still living? _______ If deceased, what age and what was
the cause of death? _____________________________________
Did your mom have any problems when she was pregnant for you?
____________________________________________________________

Past Medical Health and Family Health

Self

Mom Dad Siblings Grandparent

Diabetes:___________________________________________________
COPD/Asthma:________________________________________________
Blood Pressure:_____________________________________________
High Cholesterol:___________________________________________
Heart:______________________________________________________
Cancer:_____________________________________________________
Explain Yes answers:________________________________________
____________________________________________________________
Do you have any other health problems such as depression, anxiety, bipolar,
arthritis, joint problems, vision, hearing, bowel problems, kidney problems, liver
problems, male/female problems, etc?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What surgeries have you had? _______________________________
_____________________________________________________________
_____________________________________________________________
List other medical providers you see on a regular basis (i.e. Cardiologist, Mental
Health Provider, Kidney Doctor, etc.)
_____________________________________________________________
Employment Status: Unemployed
___________________________

Retired

Disability

Preferred language: _____________________________

Type of work:

Have you had a blood transfusion?

Have you had any serious trauma or injury?

Do you have a healthy diet?
Do you have pets?

Do you have "End of Life" directives?

Do you Exercise Sometimes

Regularly Never

Do you live in a: House Trailer Apartment Homeless

Do you have food, heat, and electricity? ___________
Are you sexually active? Any risks of sexually transmitted disease? _______________
Do you wear seat belts or use helmets when needed? _________
Do you have smoke &/or carbon detectors in the house? ______
Any Children? Please write name and DOB below
______________________________________________________________
______________________________________________________________
Any Questions or Concerns? Anything else you would like us to know about you?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Patient or Legal Guardians Signature: ________________________________
Patient or Legal Guardians Printed Name: _____________________________
Date: ___________

Provider Signature: ___________________________ Date: _____________

Temporary Delegation Of Parental Rights

Name of Minor: ___________________________ Birthdate:___________
Known Allergies: ________________________
Any limitations?:_______________________________________________
Any changes in insurance?: _____________________________________

I/we are the parents or legal guardians of the minor listed above. We appoint the
person/s listed below as a temporary delegate to bring our child or children in to Dr.
Heinlens Health Care Clinic for evaluation and treatment.

Name: _______________________ Phone Number: ____________________

Relationship to the patient/s: _________________________________

Name: _______________________ Phone Number: ____________________

Relationship to the patient/s: _________________________________
I give them permission to act on my behalf to consent to medical care including
immunizations, surgical care, and hospitalization if needed. This delegation ends
6 months after this form is signed by Michigan Law MCLA 700.5103.

Parent Signature: ________________________________ Date: ________________

Witness Signature: _______________________________ Date: ________________

Dr. Heinlens Health Care Clinic

PO Box 477
Stanton, MI 48888

Release to Give Medical Information to Another Person

Patient Name: _________________________ Birthdate: ____________

At times a patients family member or friend may call requesting information on test
results, appointment times, or other medical information. Federal law states that we
may not talk to them about your medical information without your permission.
Please list anyone whom you give us permission to talk to regarding your medical
information.

Name: __________________________________ Birthdate: ____________

Relationship: __________________ Phone Number: _________________

Name: __________________________________ Birthdate: ____________

Relationship: __________________ Phone Number: _________________

Name: __________________________________ Birthdate: ____________

Relationship: __________________ Phone Number: _________________

This authorization stays into effect until it is revoked by the patient or their legal
guardian.

Signature: ______________________________ Date: ________________

Print Name: _____________________________
Witness Signature: __________________________ Date: ____________

Dr. Heinlens Health Care Clinic

PO Box 477
Stanton, MI 48888

Dr. Heinlen's Health Care Clinic

806 N State Street, Stanton MI 48888
(989) 283-2595

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed
to other health care professionals for the purpose of evaluating your health,
diagnosing medical conditions, and providing treatment. For example, results of
laboratory tests and procedures will be available in your medical record to all health
professionals who may provide treatment or who may be consulted by staff
members.

Payment. Your health information may be used to seek payment from your health
plan, from other sources of coverage such as an automobile insurer, or from credit
card companies that you may use to pay for services. For example, your health
plan may request and receive information on dates of service, the services
provided, and the medical condition being treated.

Health care operations. Your health information may be used as necessary to

support the day-to-day activities and management of Neurosurgery, P.A. For
example, information on the services you received may be used to support
budgeting and financial reporting, and activities to evaluate and promote quality.

Law enforcement. Your health information may be disclosed to law enforcement

agencies to support government audits and inspections, to facilitate lawenforcement investigations, and to comply with government mandated reporting.

Public health reporting. Your health information may be disclosed to public

health agencies as required by law. For example, we are required to report certain
communicable diseases to the states public health department.

Other uses and disclosures require your authorization.

Disclosure of
your health information or its use for any purpose other than those listed above
requires your specific written authorization.
If you change your mind after
authorizing a use or disclosure of your information you may submit a written
revocation of the authorization. However, your decision to revoke the authorization
will not affect or undo any use or disclosure of information that occurred before you
notified us of your decision to revoke your authorization.

Additional Uses of Information

Appointment reminders. Your health information will be used by our staff to
send you appointment reminders.

Information about treatments. Your health information may be used to send

you information that you may find interesting on the treatment and management of
your medical condition.. We may also send you information describing other healthrelated products and services that we believe may interest you.

Individual Rights

You have certain rights under the federal privacy standards. These include:

The right to request restrictions on the use and disclosure of your

protected health information
The right to receive confidential communications concerning your medical
condition and treatment
The right to inspect and copy your protected health information
The right to amend or submit corrections to your protected health
information
The right to receive an accounting of how and to whom your protected
health information has been disclosed
The right to receive a printed copy of this notice

Dr. Heinlen's Health Care Clinic Duties

We are required by law to maintain the privacy of your protected health information
and to provide you with this notice of privacy practices.

We also are required to abide by the privacy policies and practices that are outlined
in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies
and practices. These changes in our policies and practices may be required by
changes in federal and state laws and regulations. Upon request, we will provide
you with the most recently revised notice on any office visit. The revised policies
and practices will be applied to all protected health information we maintain.

Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we
maintain. As permitted by federal regulation, we require that requests to inspect or
copy protected health information be submitted in writing. You may obtain a form
to request access to your records by contacting Patsy Chavez or Dr. Gary Kraus.
Your request will be reviewed and will generally be approved unless there are legal
or medical reasons to deny the request.

Complaints

If you would like to submit a comment or complaint about our privacy practices, you
can do so by sending a letter outlining your concerns to:

Dr. Heinlen's Health Care Clinic

PO Box 477
Stanton, MI 48888

If you believe that your privacy rights have been violated, you should call the
matter to our attention by sending a letter describing the cause of your concern to
the same address.

You will not be penalized or otherwise retaliated against for filing a complaint.

Contact Person

Lene' Heinlen, DO (989) 283-2595

I have received a copy of the Notice of Privacy Practices.

________________________________________________________________________
Patient or Legal Guardians Signature
________________________________________
Patient or Legal Guardians Printed Name

Date