Petoskey Urgent Care

 

Please fill out these forms prior to your visit to Northern Michigan MedCenter to expedite your experience.

Thank you and we look forward to seeing you soon.

        If you have a co-pay, deductible, or coinsurance, it is due at the time of service. Do not ask our staff to "bill it to you." They are required to follow office policy. The amount collected at time of service is an ESTIMATE based on information provided by your insurance. If incorrect benefits are given, you will be responsible for the remaining balance.

        How will you be paying today?

        ph: 231-487-2000

        Mailing Address:
        1890 US 131 #4
        Petoskey, MI 49770

        We require keeping your credit / debit card on file as a convenient method of payment for any amount that may be your responsibility at a later date. Your card information is kept confidential and secure. Payments to your card are processed only after the claim has been processed by your insurer, the insurance portion of the claim has been paid and posted to the account, and it has been determined we did not collect the full amount at the time of service.

        **ALL BALANCES UNDER $20 WILL BE RUN AUTOMATICALLY**

        I authorize Northern Michigan MedCenter to charge the credit, debit, or HSA card listed below for balances due for services rendered that my insurance company identifies as my financial responsibility. If you'd prefer not to enter the CC number and would rather have your card scanned into your account, please notify the receptionist at your visit.

        Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

        By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

        The patient understands that:

        • Protected health information may be disclosed or used for treatment, payment, or health care operations.
        • The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
        • The Practice reserves the right to change the Notice of Privacy Practices.
        • The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
        • The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
        • The Practice may condition receipt of treatment upon the execution of this Consent.

        ph: 231-348-2828

        Mailing Address:
        116 W. Mitchell St.
        Petoskey, MI 49770

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        ph: 231-487-2000

        Mailing Address:
        1890 US 131 #4
        Petoskey, MI 49770

         

        Northern Michigan MedCenter Petoskey South

        1890 US-131 #4
        Petoskey, MI   49770

        Monday thru Friday
        8:00am - 6:00pm

        Saturday & Sunday
        9:00am - 3:00pm

        (231) 487-2000 - Phone
        (231) 487 2039 - Fax

        Northern Michigan MedCenter Petoskey North

        116 West Mitchell Street
        (across from Mancino's)
        Petoskey, MI   49770

        Monday thru Friday
        8:00am - 6:00pm

        Saturday & Sunday
        9:00am - 4:00pm

        (231) 348-2828 - Phone
        (231) 348-9609 - Fax

        Northern Michigan MedCenter Boyne

        1249 M-75
        Boyne City, MI  49712

        Monday thru Friday
        8:00am - 6:00pm

        Saturday & Sunday
        Closed

        (231) 582-1515 - Phone
        (231) 582-2425 - Fax