📍 15222 E Jefferson Ave Ste B, Grosse Pointe Park, MI 48230|📞 (313) 822-2122|📠 Fax: (313) 822-2224|🕐 Mon – Wed: 8:00 AM – 2:00 PM
New Patients
Complete your intake form before your visit
Fill out our New Patient Information Form online before your appointment. It takes about 10 minutes and goes directly to our team so we can prepare your chart in advance.
Sierra Medical Associates — Dr. Michael S. Pieh, MD
New Patient Information Form
15:00
HIPAA Protected: Your information is encrypted before transmission and never stored in your browser. This session will automatically expire after 15 minutes of inactivity.
Financial Responsibility Agreement
I understand that all medical costs incurred by me are my responsibility, including any charges my insurance fails to pay and/or any deductibles or co-insurance that my insurance coverage requires. I also understand that I am responsible for paying any co-payments at the time of service.
Assignment of Benefits
I authorize Sierra Medical Associates to submit all necessary documentation needed to receive payment from my insurance company. All payments billed to my insurance for my medical care will be made payable to Sierra Medical Associates.
Consent to Contact
I authorize Sierra Medical Associates to contact me via phone call, text message, and/or email for appointment reminders, test results, and other health-related communications as indicated in my Communication Preferences. I understand that I may revoke this authorization at any time by notifying the office in writing.
HIPAA Notice of Privacy Practices
Sierra Medical Associates is committed to protecting your health information. We are required by law to maintain the privacy of protected health information (PHI) and to provide you with notice of our legal duties and privacy practices. We may use and disclose your PHI for treatment, payment, and healthcare operations without your written authorization. We will not use or disclose your PHI for any other purpose without your prior written authorization, except as required by law. You have the right to inspect and copy your PHI, request restrictions on its use, request confidential communications, amend your PHI, and receive an accounting of disclosures. To exercise these rights, contact our office in writing.
Your completed form will be AES-256 encrypted and transmitted securely over HTTPS to our office. No PHI is stored in your browser. You will receive a confirmation once submitted.
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Form Submitted Securely
Your encrypted intake form has been transmitted to our office. We will review it before your appointment. All PHI has been cleared from this browser session.