Forms You Can Download
Advance Directive & Advocate Designation
Michigan Advance Directive &
Michigan Patient Advocate Designation Form
The attached forms protect your right to refuse medical treatment you do not want or to request treatment you do want in the event you lose the ability to make decisions yourself.
The Michigan Patient Advocate Designation lets you name someone to make decisions about your medical care — including decisions about life support, mental health treatment and anatomical gifts — if you can no longer speak for yourself. The patient advocate designation is especially useful because it appoints someone to speak for you any time you are unable to make your own health care treatment decisions, not only at the end of your life.
Patient Provider Agreement (PPA)Working Together for Your Health
The health and wellness of our patients is a top concern of this office. Providing the best possible care to every patient is our primary goal. The only way we can meet this goal is if I, your doctor, and you, my patient, work together. This concept is called the Patient Centered Medical Home.
Read more: Patient Provider Agreement (PPA)
Notice of Privacy Practices
Patient Notice of Privacy Practices
BE WELL MEDICAL CENTER
A Division of Michigan Healthcare Professionals
As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996-(HIPAA) Health Information Technology for Economic and Clinical Health Act (HITECH Act), and associated regulations and amendments. You may download this form by clicking here.
This notice describes how health information about you may be used and disclosed, and how you can get access to this information.Read more: Notice of Privacy Practices
HIV Testing & InformationHIV Rapid Testing with Results in Minutes
The Human Immunodeficiency Virus (HIV) is the virus that causes Acquired Immune Deficiency Syndrome (AIDS). An HIV test will tell you whether you have been infected with the HIV virus.
We offer a rapid test which is performed on a specimen of blood. The results are available to you in about one hour. If you test negative on this test no further testing is necessary and you are negative.Read more: HIV Testing & Information
Consent Form For HIV Test
The HIV test looks for infection with the AIDS virus.
I understand that if this test shows that I have the HIV virus, I am most probably infected and could spread this to someone else. I could pass the virus to someone I am having sex with, someone I am sharing a needle with, or to my unborn baby if I am pregnant. If the test results are negative for the HIV virus, I understand I might still have the virus but that it is too early to tell by the HIV test.
Transitioning of Medical Care PolicyWe keep a record of the health care services provided to you. You may ask to examine and/or request a copy of your records. You may also ask to correct that record. Read more: Transitioning of Medical Care Policy
Prescription Refill Policy
BE WELL MEDICAL CENTER
PRESCRIPTION REFILL POLICY
Date: October 21, 2010
Background: To maintain an efficient office, provide quality medical care, and avoid any possible prescription abuses, an office policy should be maintained and followed for prescription refills. This policy needs to be clearly communicated to the entire staff and all patients.
Policy: All prescription refill requests should originate from the patient by contacting their pharmacist asking to request the refill electronically. All refill requests should be approved or disapproved by our office in 24 hours or less. The reason for any disapproval should be given electronically through RxNT. Routine prescription refills may not be fulfilled during the weekends, so patients need to plan ahead.
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