Revised 7/30/2015

Welcome to Bronson Family Practice Oshtemo We believe that patients and families are partners in care. We want to get to know you and your family. The best way to do this is with good communication between you, your family, and our staff. Ask questions and tell us your concerns. We are happy to talk about your medical needs and procedures. We can also give you information to take home. Family medicine focuses on the care and treatment of all family members including adults and children. Family medicine doctors and physician assistants offer a wide range of services. Our role is to manage your treatment to make sure your needs are being met. We help with your care throughout the healthcare system. Please take a moment to read this information. We hope this information will help you to know more about our office and our providers. If you have a question, please ask. We want to know how we can better meet your needs.

Office Hours and Appointments Our office is open from 7 a.m. to 7:00 p.m. on Monday and 7 a.m. to 5:30 p.m., Tuesday through Friday. Please call for an office appointment. Some evening hours are available. Follow-up appointments are made before you leave the office. There are times when we may need to change your appointment due to an emergency. We are sorry for any problems this may cause. For your convenience, Bronson Diagnostics Oshtemo is located in our building. This makes it easy if you need X-Rays or blood tests. For problems such as colds, flu or abdominal pain, we will try to see you the same day you call. Please call early in the day. If the doctor or physician assistant you ask for is not here when you call and you need to be seen, one of our other doctors or physician assistants will be glad to see you. Our goal is to make sure that all patients are seen as quickly as possible. If you are late for your appointment, we may ask you to change to another time.

Your First Appointment Your doctor or physician assistant needs to know about your health history to provide the best care for you. These forms will be mailed to you. If you do not get them before your visit, please come to the office 15 minutes early to complete the forms. Your first visit will include a review of your health history. A physical exam will be scheduled for another time. Please bring a list of any medicines that you are taking. Make sure we have any of your other medical records.

Young Patients A parent or guardian must come with any child under 18 years of age for their appointment or give permission for treatment. The parent or guardian can give permission with a letter or consent form. The child needs to bring the letter or consent form to the appointment. Consent forms are available at our office.

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Canceling an Appointment We know that things may happen that make it hard to keep your appointment. We do ask that you call our office to let us know the day before your appointment if you cannot come to the office when you are scheduled. This helps us to be able to see other patients who need to see the doctor or physician assistant. If you don’t call and miss visits, or call late several times, we may ask you to find another doctor.

Emergency & After Hours Calls A provider is on-call at all times to help with emergencies. If you feel your emergency is a matter of life or death, call 911 or go to the nearest emergency room. If you have an urgent need after hours, please call our office and you will be redirected and able to talk with a triage nurse. The nurse will help decide if you should stay at home and rest, schedule an appointment with your provider or seek emergency care.

Calling the Office Please call the office during the hours we are open to make an appointment, ask for prescription refills or discuss minor questions or problems.

Prescriptions We can often send your prescription to your pharmacy electronically. Some prescriptions still require a paper prescription that we can either send to you in the mail or you can pick it up from our office. We can also give you a list of your medicines, including how much you take and other important information. You will have this list for your own records or to share with other doctors. If you use a mail order pharmacy, we will mail the prescriptions to you since we cannot fax prescriptions to the mail order pharmacy. Please bring your actual medicine bottles with you when you come to the office. If you don’t bring the medicine, bring a list of all the medicines you are taking with you. Be sure to ask for refill prescriptions while you are at the office so you do not run out of medicine. If you call later for refills, it may take up to two business days to get the prescription. We do not give prescriptions for new medicine, antibiotics or pain medicine over the phone. We need to see you in the office before ordering these medications.

Seeing Another Kind of Doctor If you need a referral or authorization from our office to see another kind of doctor or have a procedure, please call our office at least one week before your appointment. We can let your insurance company know why you need to have this appointment. This will help you get the best benefit from your insurance plan. It is important for you to get authorization before your visit. If you do not get your approval before your appointment, you may have to pay for the visit yourself. We cannot authorize visits that have already happened.

Hospitalization Our doctors and physician assistants only see patients at our office. If you need to go to the hospital, you will be cared for by a doctor at that hospital. If you are admitted to Bronson Methodist Hospital, another doctor will take care of you and keep your Bronson Family Practice Oshtemo doctor and physician assistant aware of treatment of your illness or injury. After you

Revised 7/30/2015

leave the hospital, you will see your Bronson Family Practice Oshtemo doctor or physician assistant for follow-up care.

Fees and Insurance Payment for the care you get in our office may be covered by your medical insurance. Please bring your insurance card(s) with you to each appointment. We accept most insurance carriers and will send claims to those carriers for services we do in our office. You will get different bills for lab, X-Ray and other testing procedures. Billing for these services will be sent to you or your insurance company. Your insurance carrier can best explain what things will be paid for in your medical plan. Examples might be:

• Things we do to prevent illness. • When they need approval for other services. • What things have to be approved by them before you have the service. • Where you can have a service like lab or X-Rays.

Please tell our staff if your labs must be sent to a facility other than Bronson Methodist Hospital. If your insurance carrier requires approvals like a referral or prior authorization, you must call your insurance carrier or let us know before your appointment. You may need to pay for part of the charge at the time of your visit. We accept cash, checks and most major credit cards. For patients without health insurance, a discount will be given to patients who pay the entire amount before they leave the office. If everything is not paid, a bill will be sent to you. We charge a small fee for copies of your medical records or for filling out medical forms. If you have trouble paying a bill, need help with paying a bill or have questions about fees or insurance, please contact our billing department at (269) 353-9898, Monday through Friday, 8 a.m. to 4:30 p.m.

Questions Call our office if you need:

• Non-medical information • Medication refill • Schedule an appointment

Our staff keeps all of your information confidential. If you call our office and a staff member isn’t available, please give us as much information as possible. We will call you back as soon as possible. It may take some time since the providers are seeing other people during the day.

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Bronson Family Practice Oshtemo 5629 Stadium Drive, Suite D Kalamazoo, MI 49009 (269) 372-5701 Fax: (269) 372-5702 bronsonhealth.com

Bronson Family Practice Oshtemo 5629 Stadium Drive, Suite DKalamazoo, MI 49009(269) 372-5701(269) 372-5702 fax

bronsonhealth.com/primarycare

BRONSON FAMILY PRACTICE OSHTEMO

0225 9/15

Sean Brandt, DO

Troy Green, PA-C

Misty Miller, PA-C

GretchenMichalowski, PA-C

Bart Lewis, DO

At Bronson Family Practice Oshtemo, we focus on the care and

treatment of all family members including adults and children.

We will partner with you and your family to manage your treatment

in all areas of healthcare.

Our offices are connected with an electronic medical record, so

your care is easily coordinated among all of your Bronson doctors.

And you can partner in your care through Bronson MyChart — an

online health record that gives you free and secure access to

information about your health. It helps you to quickly request

appointments, talk with your doctor, order prescription

renewals and view test results.

For more information about our practice and our providers,

visit bronsonhealth.com. You can also call us at

(269) 372-5701.

Family Practice Oshtemo

BRONSONFAMILYPRACTICEOSHTEMO

PARKVIEW

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Our Services•Geriatriccare•Men’shealth•Nutritioninformation•Pediatriccare•Physicalexams•Preventivecare•Immunizations•Women’shealth

Some of the Conditions we Treat•Abdominalpain•Acne•Asthma•Colds&flu•Diabetes•Highbloodpressure•Infections•Warts

Our practice is excited to provide our patients

with nurse triage services after normal

business hours and on weekends!

By simply making a phone call to our office,

you will be automatically redirected and able

to talk with a nurse about urgent needs. The

nurse will help decide if you should stay home

and rest, schedule an appointment with your

provider or seek emergency care.

This is part of Bronson’s commitment to our

patients to provide the right care at the right

time in the right place.

Talk to our office staff or your provider to

learn about how this can help improve your

healthcare experience.

After Hours Nurse Triage

Services Now Available

Bronson’s Appointment Text Reminder Message

Types of preventive Medicare visits:

“Welcome to Medicare Visit” Bronson does not offer this service at this time.

“Annual Wellness Exam” Bronson does not offer this service at this time.

*Routine Physical Exam Your healthcare provider

recommends routine physical exams. These exams offer

more than the “Annual Wellness Visits,” but they are not

covered by Medicare.

• Review your medical and social history.

• Record your height, weight and blood pressure.

• Find out your body mass index.

• Educate, counsel and/or refer you based on your

needs – he/she may talk to you about risk factors you

may have or screenings tests you need.

• Listen to your heart and lungs.

• Check your eyes, ears, nose and throat.

• Feel your stomach and other parts of your body.

Cost not covered by

Medicare.

Care provided by a

provider (Dr., PA, NP,

RN)

*Medicare does not cover routine physical exams. If you do not have other insurance,

you may have to pay for this visit in full.

It’s okay to ask questions.

Call your doctor’s office to learn more before your visit.

Medicare Patient Information (Part B)

Page 1 of 2

Request for Access or Authorization for Use and Disclosure of Protected Health Information

Patient Name: _____________________________________________________________________ Last First MI Date of Birth: _________________________________ Month Day Year I give permission to Bronson Medical Practices to use or disclose my protected health information indicated below to

Physician to release records:

Name: ________________________________

Address: ______________________________

__

Phone: __

Fax: __

Physician/Person to receive records:

Name: ________________________________

Address: ______________________________

________

Phone: __

Fax: __ Information to be released:

(Please check boxes that apply)

ð Discharge Summary

ð History and Physical Exam

ð Progress Notes

ð Lab Reports

ð X-Ray Reports

ð Medication Records

ð Detailed Bill

Other (specify content and dates) ______________________________________________________

Purpose of Disclosure:

ð Changing doctors

ð Consultation

ð Insurance or Workers’ Compensation

ð School

ð Research

ð At request of individual

ð Legal (specify) _______________________________________________________________

ð Other (specify) _______________________________________________________________

ð For my own use

Page 2 of 2

I authorize the release of health information, contained in my medical records including:

• Information regarding communicable diseases and infections, as defined by statue and Michigan

Department of Health rules, which include venereal disease, Tuberculosis, Hepatitis A, B, C,

Human Immunodeficiency Virus (HIV), HIV testing.

• Acquired Immunodeficiency Syndrome (AIDS) and AIDS related complex (ARC).

• Alcohol and drug abuse treatment information protected under the regulations in CFR 42, Part 2.

• Mental health treatment records, psychological services and social services information including

communications made by me to a social worker, therapist, or psychologist.

Acknowledgement of Understanding:

• I understand this authorization will expire in one year from date signed.

• I can cancel this authorization at any time by writing to Bronson Medical Group.

• It will take effect on the date notified, except if action has already been taken.

• I understand that if I release my medical record to a person or provider, they can release my

medical record. I know I need to check with them about their privacy rules.

• I will get an abstract of my medical record unless I ask for the complete record.

• No conditions will be placed on me if I sign this form.

Michigan law says I may have to pay for:

• Copies of my record

• Inspection of my record

• Written summary of findings

Bronson Medical Practices will not benefit from disclosing this information.

____________________________________________________ ___________________________

Signature of Patient Date

____________________________________________________ ___________________________

Parent or Personal Representative Date

Affix Patient Label

*9004286*

9004286 (11/13) Intranet Patient Demographics Page 1 of 4

(Bronson Medical Practices)

Patient Demographics Demographics – Patient Information

Last Name: _____________________ First Name: _________________ Middle Name: _____________

SSN: ________/_______/_______ Sex: M / F / U Birth Date: ____/____/____

Address: ____________________________ Home Phone: __________________

____________________________ Work Phone: ___________________

City: _______________________________ Cell Phone: ____________________

State: __________ Zip: ______ E-Mail Address: ________________

Other Communication

Allowed Communication: ____ Do Not Contact ____ Mail ____ Phone ______Text

____E –mail ____ MyChart Signup

Needs Interpreter? Y/ N Language: ________________________

Marital Status: __________________ Religion: _________________________

Ethnicity: Hispanic/ Not Hispanic

Race: ______________

PCP Care Provider Information

Primary Care Physician: _________________________________________________________________

Emergency Contact – In Case of Emergency, who to contact

Last Name: _______________________ First Name: __________________ Middle Name: ___________

Relation to Patient: ________________________

Home Phone: __________________ Work Phone: _______________ Cell Phone: _________________

Patient Employment

Employer: ___________________________ Employment Status: _____ Not Employed

Affix Patient Label

Patient Name:____________________ DOB:_________________

9004286 (11/13) Intranet Patient Demographics Page 2 of 4

(Bronson Medical Practices)

Employer Address: ____________________ Employment date: _____________________

City: _________________________ Employee ID: __________________________________

State: ________ Zip: __________ Occupation:_____________________________________

Phone: _______________________ Fax: __________________________________________

Religious Affiliation

Church: ______________________________________________________________

Guarantor Accounts – If patient is over 18 years of age, see patient information

Last Name: _______________________ First Name: __________________ Middle Name:__________

Account Type: Patient/Family / Workers Comp / Auto SSN: ________/_______/_______

Sex: M/F/U Birth Date: ____/____/____ Relation to Patient: ________________________

Address: _________________________ City: _________________________

_________________________ State: __________ Zip: ______

Home Phone: __________________

Guarantor Employer: ___________________ Employ. Status: Full Time / Part Time

Address: _____________________________ City: _________________________

_____________________________ State: __________ Zip: ______

Phone: __________________

Primary Coverage

Name of Coverage: _______________________________________________________________

Member Relationship to Subscriber: __________________________________________________

Affix Patient Label

Patient Name:____________________ DOB:_________________

9004286 (11/13) Intranet Patient Demographics Page 3 of 4

(Bronson Medical Practices)

Insurance ID: ________________________ Member Effective Date: ________________________

Group Number: ______________________ Group Name: ________________________________

Authorization Phone: ________________________________

Covered Through: Employment / Retirement Employer size: _________________________

Subscriber Name: ___________________ SSN: ________/_______/_______ Sex: M/ F / U

Birth Date: ____/____/____

Subscribers Address_____________________________ City: ___________________________

_____________________________ State: __________ Zip: __________

Subscriber Phone: ____________________

Secondary Coverage

Name of Coverage: ________________________________________________________________

Member Relationship to Subscriber: ___________________________________________________

Insurance ID: ________________________ Member Effective Date: ________________________

Group Number: ______________________ Group Name: _________________________________

Authorization Phone: ___________________________

Covered Through: Employment / Retirement Employer size: __________________________

Subscriber Name: ___________________ SSN: ________/_______/_______ Sex: M/ F / U

Birth Date: ____/____/____

Subscribers Address_____________________________ City: _____________________________

_____________________________ State: __________ Zip: ______

Subscriber Phone: _____________________________

Affix Patient Label

Patient Name:____________________ DOB:_________________

9004286 (11/13) Intranet Patient Demographics Page 4 of 4

(Bronson Medical Practices)

Visit Specific Information

Reason for Visit: ____________________________________________

Accident Related: Y / N If Yes, Fill out Accident Information below

Accident Date: ____________________ Accident Time: ___________________

Accident Type: _____________________ Place of Injury: Home / Work / Other

Body Part Injured: __________________ Accident Description: ________________________

______________________________________________________________________________

Referring Physician (if applicable):________________________________________________________

MRN_________________________________________________

CSN__________________________________________________

Patient's Name:_____________________________ Date of Birth: ________________

Allergies: ___________________________________________________________________

Primary Physician:____________________________________________________________

Pharmacy (Include location):____________________________________________________

List ALL Medications Below

*Include Over-the_Counter/Vitamins/Herbal Supplements

PATIENT INFORMATION & HOME MEDICATION LIST

Example: Aspirin

Doses/Strength

81 mg 1 tablet every morning

Name of Medication How Many/How Often

25)

16)

17)

18)

19)

20)

21)

13)

14)

22)

23)

24)

Please bring this completed to your appointment

Thank you!

15)

For Your Safety, Please Update When Your Medications Change

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2)

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Patient and Provider Partners in Care

The Patient Centered Medical Home (PCMH) is a way of offering you the best possible healthcare. The goal of the PCMH is to create a healthcare

setting that builds a partnership between you, your provider’s team, and if desired, your family.

At Bronson Family Practice Oshtemo, you will have an ongoing relationship with your doctor. Your doctor leads a team that takes responsibility for

you. This team is in charge of all your healthcare needs. Or, when needed, arranges for care with another doctor.

As your healthcare team we pledge to:

Include you as a member of your healthcare team, treating you

with respect, honesty and compassion.

Encourage you to define your ‘family’. This can include family,

friends, and other support people. Work with you to decide how

and when you want your ‘family’ included.

Hold ourselves to the highest quality and safety standards. Exceed

your expectations for your healthcare experience.

Be responsive and timely with our care and information to you.

Respect your time. Reduce and explain any delays.

Help you to set goals for your healthcare and plan of care.

Talk with you in words that are clear and understandable. Listen to

you and answer your questions.

Respect your right to see your own medical information.

Respect your privacy and the privacy of your medical information.

Give you information to help you make informed decisions about

your care and treatment options. This includes risks and benefits of

your care.

Work with you and other team members who treat you.

Maintain a clean, safe and quiet office.

As a patient I pledge to:

Be a responsible and active member of my healthcare team. I will

treat you with respect, honesty and consideration.

Tell you who is important to me and who I define as ‘family’. Tell

you how and when I want people in my ‘family’ to take part in my

care.

Be on time for my scheduled appointment. Limit disruptions and

stay focused during my appointment.

Help make decisions about my care.

Ask questions when I do not understand and until I do understand.

Give you all the information that you need to treat me.

o Drugs I am taking

o Other doctors I may see

Learn all that I can about my condition and plan of care.

Know that what I do affects my health.

I will do my best to carry out our agreed upon plan of care. If I

can’t, I will tell you.

Tell you if your office isn’t clean, safe and quiet.

BRONSON STATEMENT ON PATIENT RIGHTS AND RESPONSIBILITIESBecause Bronson respects the rights and human dignity of eachpatient, patient rights and responsibilities are given upon admissionor upon request.

We are committed to making your experience at Bronson aspositive as possible. If you have concerns, complaints, orsuggestions, please contact the Patient Relations Office at(269) 341-8959.

The Patient Rights and Organizational Ethics Committee also existsto help patients and their families make informed choices aboutdifficult decisions that may involve ethical issues. They may bereached by calling the Bronson operator at (269) 341-7654.

The Right to Information You Can Understand During YourHospital AdmissionYou have the right to:

• know about Bronson’s policy of Patient Rights andResponsibilities and Advance Directives

• contact a Bronson Patient Representative if there is aquestion, concern or complaint about any service

• file a grievance with the hospital or external agency andto be informed of the procedure for initiation, reviewand resolution of a grievance or complaint

• know about services and the charges for services; to haveyour hospital bill explained; and to know about financialhelp offered by the hospital

• know who is giving your care; to information about yourhealth and treatment plan; to know about your future healthcare needs; and the right to be involved in discharge plans

• agree to or refuse treatment; to be told the risks of treatment;and the right to be told what will happen if you refusetreatment; and know about Bronson’s rules that affectpatient care and conduct

The Right to Dignified, Respectful, Considerate CareYou have the right to:

• care regardless of age, race, color, creed, national origin,sex, religion, marital status, sexual orientation, disabilityor your ability to pay for care

• be free from mental or physical mistreatment; be free fromrestraints unless ordered by a physician for your safety orthe safety of others; and to correct alternatives to restraints.If restraint is used, the least restrictive method will be usedand it will be stopped as soon as possible.

The Right to a Reasonable Response to Your RequestsYou have the right to:

• have a reasonable response to your needs for treatmentand service within Bronson’s ability

• request generic or trade brand drugs• have your civil and religious rights and your cultural and

spiritual beliefs respected to the extent that they do notinterfere with the well being of others

The Right to Personal Privacy and Confidentiality ofYour Medical Treatment and Medical RecordsYou have the right to:

• have your personal and medical records treated with privacy;to review your medical record; and to obtain a copy of yourmedical record. Your record cannot be given to anyonewithout your permission, unless required by law, third partypayment contract, or hospital accrediting agency.

• talk privately with your physician, attorney or other person• send and receive unopened personal mail

• be treated in private; to be cared for with dignityand as an individual.

The Right to be Informed of Any Research or EducationalProjects Affecting Your Care or TreatmentYou have the right to:

• information about experimental treatment consideredin your care; and to know the risks and possible result ofrefusing this treatment

• be informed if you are part of an educational project asBronson is a teaching hospital.

Patient Responsibilities Which Will Promote a True Partnershipin Your Treatment:

• Make available a complete and correct medical history• Let us know if you understand your medical treatment• Take part in healthcare decisions with the advice of your

doctor(s) and follow the recommendations and advice ofyour doctor(s)

• Tell your doctor or nurse about any problems you haveduring your medical treatment

• Be considerate of the rights of other patients, Bronson staff,and property

• Give correct information about how you will pay your bill• Make arrangements to pay bills not paid by your insurance• Follow Bronson's rules about patient care and conduct

Bronson Statement on Pain ManagementWe believe all patients have a right to pain relief.Based on this belief we will:

• tell patients that pain relief is an important part of their care• review patient’s pain on the first evaluation• continue to look at the presence, quality and intensity of pain• consider pain monitoring the fifth vital sign and monitor pain

often based on the patient’s condition and pain state• use what the patient says about their pain as the primary

indicator of pain• accept with respect the reports a patient makes about pain• respond quickly to reports of pain• consider the special needs of children, frail and elderly

patients in the assessment and treatment of pain• work with the patient, family and other health care providers

to establish a goal for pain relief• develop and use a plan to make pain relief the goal,

including education of the patient and family• continue to review and change the care for patients who

have pain that will not stop.

If your concern is not resolved through Bronson,you may file a complaint via:

State of Michigan

Michigan Dept. of Community HealthBureau of Health ServicesComplaint Investigation UnitP.O. Box 30664Lansing, MI 48909

Request a complaint form byphone: (517) 373-9196or toll free at (800) 882-6006.

Download a complaint formonline: www.michigan.gov/mdch

Si usted desea leer los Derechos y Responsabilidades de losPacientes en español, puede llamar al (269) 341-7654.

J12587 (rev. 12/1/09) (formerly MC-1179E H3381)

The Joint Commission

Office of Quality MonitoringThe Joint CommissionOne Renaissance BoulevardOakbrook Terrace, IL 60181(800) 994-6610Fax: (630) 792-5636E-mail:complaint@jointcommission.orgwww.jointcommission.org/GeneralPublic/Complaint/

It’s OK to Ask Please ask questions and talk with your doctors, nurses and other care providers during your office visit. Talking together helps make sure you and your family member get the best care possible. There are several areas that Bronson would like you to pay close attention to: § Medications

o Bring a list of all your medicines, over-the-counter drugs, herbal supplements and vitamins to your appointments every time.

o Ask your doctor for your medication refills during your office visit. This will help make sure you take your medication without any breaks.

o Tell your doctor and nurse about your allergies. o Ask your doctor about each drug she prescribes and what it is used for. Make

sure the doctor writes the name of the drug clearly so you and the pharmacist can read it. Ask to take home written information on why you are taking the medicine and possible side effects.

o Anytime you receive a medicine, shot or intravenous (IV) fluid, the nurse or other provider should ask for your name and birthdate. This makes sure the right medication is given to the right patient.

§ Help Prevent Infections

o Ask everyone who enters your room to wash their hands or use hand sanitizer. This helps to keep you safe from other people’s germs.

o Make sure to get your flu or pneumonia vaccine. § Testing

o Ask your doctor what the tests are for and what to expect. o Find out how and when you will be told about your test results. o Call the office if you do not receive your test results when you were expecting

them.

§ Pain Management o Tell your doctor or nurse if you are uncomfortable or in pain. Most pain can be

controlled and will be addressed right away. It is OK to ask again if you feel your pain has not been addressed.

§ Help Prevent Falls

o Always wear non-skid footwear to your appointment. o Use office floor mats to wipe wet bottoms of shoes. o Get up slowly from the exam table or chair to help prevent dizziness. o When recommended, use a walker, crutches, cane or wheelchair. o Stand next to your child when they are on the exam table.

Patients and their families are the most important partners on the healthcare team. We want you to ask questions, give information, and help make decisions about your care.