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PrimeCare of Michigan > Patient Registration

Patient Registration

Which of our locations will you visit first? Please make sure you look closely as some sites may look similar.*
Patient Name*
First Name Last Name
Date of Birth*
MM slash DD slash YYYY
SS#*
Gender*
- Male
- Female
Preferred Pronoun (if applicable)
Address*
Street Address Apt. No City State Zip Code
Phone: Home*
Phone: Work
Phone: Cell
Our office will use your cell phone to send you appointment reminders.
E-Mail Address*
Secret Question – What is the last 4 of your SS #*
Preferred Language*
Ethnicity*
Who is your current primary care physician? If you don't have one, please say none.*
Which provider would you like to see at PrimeCare?*
WebView login information will be sent to your email
- View/receive results/communications online through our patient portal
WebView login information will be sent to your email
Marital Status*
- Single
- Married
- Divorced
- Widowed
Your Employer*
Who referred you to our office?*
Emergency Contact Name*
Emergency Contact Phone #*
Relationship*
I authorize PrimeCare of Michigan and/or Dr. Kelly Krueger to release my medical information to:
Name
Phone Number
Relationship to Patient
Name of Insurance*
Guarantor Name
If other than yourself
Date of Birth of the Insured Subscriber
If other than yourself
Relationship of Insured Subscriber to the Patient
If other than yourself
Insurance ID#*
Name of Secondary Insurance
If applicable
Secondary Insurance ID #
Group #*
Guarantor Name
If other than yourself
Notice of Privacy Practices – Patient Acknowledgement

Your name and signature below indicated that you have received/been offered a copy of PrimeCare of Michigan’s/Dr Kelly Krueger Notice of Privacy Practices.
Click here to review*
- I AGREE to HIPAA Notice of Privacy Policy
Click here to review
Click here to review*
- I AGREE to Payment Policy
Click here to review
*
- I authorize PrimeCare of Michigan, PLLC/Dr Kelly Krueger to provide treatment to my legal dependent or myself.
Patient/Guardian Initials*
Please note that services you receive on the date of service may not be payable by your insurance carrier. This includes charges from our office and a separate Lab charge.

You will be held responsible for payment if your insurance carrier does not cover these charges.

*** Please avoid a potential $25 fee for appointments not cancelled before 24 hours of your scheduled time. *****
Signature*
Date*
MM slash DD slash YYYY

We will see you in our office, urgent care and in the hospital.

We cannot wait to meet you!

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