Patient Forms | Records | Referrals
Fees | Insurance

Patient Forms

As a convenience, the following patient forms are available for you to print out, complete and bring to your appointment:

New Patient Packet (PDF)

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Records

For your protection, all patient's records are held in strict confidence and will not be released from this office without a written and signed authorization.

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Referrals

You do not necessarily need to be referred to our office by another physician. Self-referrals are always welcome. Please keep in mind, however, that if you're an HMO or Managed Care Insurance member, it's your responsibility to obtain authorization from the Primary Care Physician PRIOR to your visit. If authorization is not received, you will be asked to sign a waiver stating that you will be responsible for all charges incurred. Good communication with a referring physician is important to us. Should you be referred by another physician, we will keep him or her informed during the course of your treatment.

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Fees

We will be happy to discuss our fees in advance, so you're aware of your financial responsibility. For any questions you may have regarding our fees, billing, or insurance, please feel free to contact our billing office at 392-1306. If financial problems arise, please notify us, and we can work out a payment schedule.

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Insurance

Upon timely arrival to our office, please have all insurance cards available, so we may make a copy for your file. As a courtesy to our patients, we will bill all insurance carriers for services. The responsibility for payment, however, remains solely with you ­ the patient. If preferred, we'll provide you with itemized receipts to submit to your insurance carrier for reimbursement.

Please inform our receptionist of any changes in your coverage, so we can bill the appropriate carrier and avoid delays in payment. We ask that all insurance co-pays be made at the time of service. We do participate with Medicare. However, you will be billed for your deductibles and the 20% co-insurance. If you have a secondary insurance and have provided us with that information, we will file a claim with that carrier after hearing from Medicare.

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Western Michigan Urological Associates, P.L.C.

Michigan Avenue Medical Center
577 Michigan Avenue, Suite 201
Holland, Michigan 49423
Phone: 616.392.1816
Fax: 616.392.1292
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*Phone calls from our former Grand Haven office, 616-846-1870,
continue to be forwarded to our Holland Office.