555 MidTowne Street NE Suite 301Grand Rapids, MI 49503616-248-8864

Appointment Request

Information for Patients

Your first visit to Dermatology at MidTowne, PC involves a few special steps so that we can get to know you. To understand what to expect, please read through this page. You'll find all the practical information you need, such as a map and directions to our office, practice hours, payment policies and more.

You can also save some time by printing out and completing the patient forms in advance of your appointment.

Mission Statement

Excellent, compassionate, and uncompromising care is our daily mission.

To fulfill this mission, we are committed to:

  • Listening to those we are privileged to serve.
  • Earning the trust and respect of patients, professionals and our community.
  • Exceeding your expectations.
  • Ensuring a creative, challenging and compassionate professional environment.
  • Striving for continuous improvement at all levels.

Practice Hours

We see patients Monday through Friday; appointment times vary by provider and by weekday. Please call (616) 248-8864 to schedule an appointment. We are available by phone Monday through Friday from 7:30 AM to 4:30 PM. We are closed for all major holidays.

Appointments

We know you have many choices when choosing an dermatologist in Grand Rapids, MI so we have made requesting an appointment a simple and convenient process via our website. If you cannot keep a scheduled appointment for any reason, or will be delayed, please call us as soon as possible.  No show appointments may be assessed a $25.00 fee that must be paid before an appointment can be rescheduled.

For your convenience, we will send an automated reminder call or text regarding your appointment to the primary phone number you provide. When scheduling your appointment, please provide the phone number where you would like to receive this call or text. 

What To Expect

Being well-prepared for your appointment will ensure that the doctor has all of the needed information to provide the best possible care for you. It will also help alleviate any unnecessary anxiety you may be feeling prior to your first appointment. Educate yourself on your symptoms by reviewing the content on this website. Also, take some time to review our Providers page and familiarize yourself with the physicians. We look forward to your first visit.

Patient Forms & Tools

  • New Patients: please print and fill out the forms at this link so we may expedite your first visit. Please either fax them to us in advance at (616) 248-8874 or bring them with you to your first appointment.
     
  • Established Patients: please print and fill out the forms at this link so we may expedite your visit. Please either fax them to us in advance at (616) 248-8874 or bring them with you to your appointment.
     
  • You may now pay your bill online using Visa, Mastercard, or Discover. 
    (We accept American Express by phone or by mail only. If you have any trouble using the online site, please try it first using the browser Internet Explorer. If you still have trouble, please notify our billing department at (616) 248-8864 x 224. Thank you.)
  • For more information regarding payment and financing options, see below.

In order to view or print these forms you will need Adobe Acrobat Reader installed.
Click here to download it.

Insurance and Billing

We accept most traditional insurance plans. Qualifications for insurance coverage may differ due to the uniqueness of each procedure. The following is a list of the major carriers with whom we participate. If your insurance company is on this list, please note that this does *NOT* guarantee that we participate with your plan; you may be in a unique network that is not part of our contract. Please contact your insurance carrier directly to verify participation.

  • Aetna
  • ASR / Physicians Care
  • Blue Cross Blue Shield
  • Blue Care Network 
  • Cigna
  • Cofinity
  • Golden Rule
  • Humana
  • Medicare
  • Priority Health
  • United HealthCare
 

*Please note that we are not currently accepting any new patients that only have coverage through Medicaid or a Medicaid replacement policy. We participate in order to provide continuity of care to our established patients.

Payment Options

For medical services, patients are expected to pay for any identifiable and applicable co-pays at the time of their appointment. Additional payment may also be requested from patients who have not yet met their annual deductibles. For cosmetic services, payment in full is expected at the time of service. 

We accept checks, cash, or Visa, Mastercard, American Express, or Discover credit cards. We offer payment plans for patients with larger balances; these must be approved through the billing office. For patients with balances greater than $200 and less than 90 days old, we also accept CareCredit.

You may now pay your bill online using Visa, Mastercard or Discover. (Please call the office to pay with American Express.)

Financing Options

CareCredit is here to help you pay for treatments and procedures your insurance doesn't cover. They offer low monthly payment options, no up-front costs, no pre-payment penalties, and no annual fees so you can get what you want when you want it.

CareCredit is accepted by over 100,000 providers and is the nation's leading patient financing program. For more information, visit www.carecredit.com or contact our office.

Financial Policy

Patients are expected to pay for any identifiable and applicable co-pays at the time of their appointment. Patients who are covered by private, commercial insurance plans that our physicians do not participate with are required to pay one hundred percent (100%) of the bill at the time of service. If they are covered by a plan with which we have a contract, applicable and determinable co-payments and deductibles will be collected at the time of service. Patients are responsible for paying one hundred percent (100%) of non-covered or cosmetic services. Payments for amounts billed are due within twenty (20) days of receiving a statement. At their appointment, patients will be asked to sign an agreement confirming their compliance with this policy. Patients who are unwilling to sign the agreement may not be seen by the physician.

Notice of Privacy Practices  (*Revised 09/2013)

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

PLEASE READ IT CAREFULLY

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, the right to understand and control how your protected health information ("PHI") is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operation.

  • Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this is a primary care doctor referring you to a specialist doctor. 
  • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would include sending your insurance company a bill for your visit and/or verifying coverage prior to a surgery. 
  • Health Care Operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost-management analysis, and customer service. An example of this would be new patient survey cards. 
  • The practice may also be required or permitted to disclose your PHI for law enforcement and other legitimate reasons. In all situations, we shall do our best to assure its continued confidentiality to the extent possible.

We may also create and distribute de-identified health information by removing all reference to individually identifiable information.

We may contact you, by phone or in writing, to provide appointment reminders or information about treatment alternatives or other health-related benefits and services, in addition to other fundraising communications, that may be of interest to you. You do have the right to "opt out" with respect to receiving fundraising communications from us.

The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:

  • Most uses and disclosure of psychotherapy notes; 
  • Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations; 
  • Disclosures that constitute a sale of PHI under HIPAA; and 
  • Other uses and disclosures not described in this notice.

You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your prior authorization.

You may have the following rights with respect to your PHI:

  • The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it. 
  • The right to reasonable requests to receive confidential communications of Protected Health Information by alternative means or at alternative locations. 
  • The right to inspect and copy your PHI. 
  • The right to amend your PHI. 
  • The right to receive an accounting of disclosures of your PHI. 
  • The right to obtain a paper copy of this notice from us upon request. 
  • The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.

If you have paid for services "out of pocket", in full and in advance, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure.

We are required by law to maintain the privacy of your PHI and to provide you the notice of our legal duties and our privacy practice with respect to PHI.

This notice if effective as of  09/2013 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPAA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain. We will post a copy and you may request a written copy of the revised Notice of Privacy Practice from our office.

You have recourse if you feel that your protections have been violated by our office. You have the right to file a formal, written complaint with the practice and with the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.

Feel free to contact the Practice Compliance Officer, Kelly, 616-248-8864 x201 for more information, in person or in writing.

Dermtology at MidTowne, PC complies with applicable Federal civic rights lawas and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Back to top

Back
to
Top