New Patient Forms
Please email these two forms, or print out the PDF versions, fill them out and bring them with you on your first visit:
Registration Form (PDF)
Medical-Information Form (PDF)
Referring Physician Patient Form:
Please email us your patient’s information or print out the pdf version, fill out and fax it to 231-775-0744. Thank you.
Referring Physician-Patient Form (PDF)
Questionnaires for Specific Difficulties
Please print the appropriate form, fill it out, and bring it with you on your next visit:
If you are having problems with erectile difficulties, click here.
If you are having problems with your prostate, including incomplete emptying, frequency, intermittency, urgency, weak stream, straining, or frequent nighttime urination, click here (I-PSS).
If you are having urinary difficulties including frequency and urgency, click here (Patient Assessment).
Documents are in PDF format. If you have difficulty opening a document, you may download a free PDF reader by clicking here.
— — — Privacy Statement — — —
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact:
Cindy Long, Business Administrator, at (231) 779-2565.
Your medical information is personal and we are committed to protecting this information. We create a record of the care and services you receive at our office and these records are used to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by this office whether made by your personal physician or one of the office’s employees.
This Notice will tell you about the ways in which we may use and disclose your medical information. This Notice will also describe your rights and certain obligations we have regarding the use and disclosure of your medical records.
This office is required by law to:
(1) make sure that medical information that identifies you is kept private
(2) give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
(3) follow the terms of the Notice that is currently in effect.
How this Office May Use and Disclose Your Medical Information
The following describes the different ways that your medical information may be used or disclosed by this office. For clarification, some examples have been included. All of the ways we are permitted to use and disclose your medical information will fit with in one of these general categories:
For Treatment We will use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians and other office personnel who are involved in providing you medical treatment.
For Payment We may use and disclose medical information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party. We may need to give your health plan information about treatment that you have received or are going to receive to obtain payment or prior approval.
For Health Care Operations We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run our office and make sure that all of our patients receive quality care.
Appointment Reminders We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at this office.
Treatment Alternative We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
As Required By Law We will disclose medical information about you when required to do so by federal, state or local law. Disclosures may be required by Worker’s Compensation statues and various public health statues in connection with required reporting of certain diseases, child abuse and neglect, domestic violence, adverse drug reactions, etc.
Health Oversight Activities We may disclose medical information to a governmental or other oversight agency for activities authorized by law.
Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may use your medical information to defend the office or to respond to a court order.
Law Enforcement We may release medical information about you if required by law when asked to do so by law enforcement official.
Coroners and Medical Examiners We may release medical information to a coroner or medical examiner to identify a deceased person or determine the cause of death.
Marketing We will not provide your medical information to any other person or company for marketing of any products or services other than Cadillac Urology Practice’s products or services unless you have signed an authorization.
Your Rights Regarding Your Medical Information
You have the following rights regarding the medical information this office maintains about you:
Right to Inspect and Copy You have the right to request a copy of your medical information with the exception of any psychotherapy notes.
Your request must be made either in person or in writing to our office. Your medical information will only be released to you. You will be required to present a photo ID.
Right to Amend If you feel that the medical information that we have about you is incorrect or incomplete, please let our office know and we will make all necessary amendments.
We may deny your request if you ask us to amend information that:
(A) Was not created by us
(B) Is not part of the medical information kept by this office
(C) Is not part of the information which you would be permitted to inspect and copy
(D) Is accurate and complete.
Right to Request Confidential Communications You have the right to request that we communicate with you only in a certain manner. For example, you can ask that we only contact you at work or by mail.
Right to Restrict Disclosure to Health Plan You have the right to request restriction of disclosure to a health
plan for health care services provided or products received when those services or products are paid for with cash, out of pocket, before services are provided. Upon full payment, then you have the right to request that your health insurance not be notified of the service or product.
Sale of Medical Information We do not sell, exchange or in any way provide personally identifiable information to any third-party organization.
Notice of a Privacy Breach If a breach of unsecured medical information occurs which poses a significant risk of harm to the individual, we are required to notify the individual of the breach of unsecured medical information.
If you have a complaint regarding this Notice of Privacy or the Law, please contact Cindy Long, Office Manager, at (231)-779-2565.