Patient Information and Forms

Prescription Refills:
Patients may call 24 hours per day and leave a message for prescription refills but must allow two business days for pharmacy refills or personal pick up.

Physician Office Referrals:
Kalamazoo Anesthesiology Pain Consultants appreciates your confidence and trust in referring your patients to us. As a multidisciplinary pain clinic, we will treat all aspects of your patient’s pain including occupational therapy, psychology and medical management.

Self Referrals:
If you would like to become a patient at Kalamazoo Anesthesiology Pain Consultants you will need to have a primary care physician. Please contact one of our schedulers at (269) 381-7246 and they will walk you through the referral process and answer any questions you may have.

Patient Forms:

• Fee and Cancelation Policy Form (PDF)
  
  
• Initial Patient Interview Form (PDF)
  
  
• Notice of Privacy Practices Form (PDF)
  
  
• Medical Record Release Form (PDF)
  
  
• Patient Referral Form (PDF)

Office Policies:

Payment Policies – All payment is expected at the time of service
This includes applicable co-insurance and co-payments for participating insurance carriers. Kalamazoo Anesthesiology Pain Consultants accepts cash, personal checks, Visa, Mastercard, and Discover. There is a service charge for returned checks.

Insurances
We will bill participating insurance companies as a courtesy to you.  You are expected to pay your deductibles and co-payments at the time of service. If we have not received payment from your insurance company, you will be expected to pay the balance in full.

Billing Questions
If you need any assistance or have questions, please call our billing department between 8:00am and 5:00pm, Monday through Friday at 269-345-8618.

Missed Appointments/Untimely Cancellations
Missed appointments represent a cost to us, to you and to other patients. If you are unable to keep your appointment please give 24 hours notice to avoid charge. We reserve the right to charge for missed or untimely canceled appointments. Excessive abuse of scheduled appointments may result in discharge from the practice.