SCHEDULING YOUR FIRST VISIT
We will contact you to schedule your initial appointment after we receive the forms below. The paperwork needed for your first visit can be printed out, completed and:
scanned and emailed to omason@attention.md
faxed to (877) 411-1871
Email or Fax is preferred but you can also mail it to us at: 2537 Indian Trail SE, Grand Rapids, MI 49506. We recommend making a copy for yourself before mailing.
If you have the computer skills, the .doc forms can be completed in your word processor. Please remember to save the completed form in .doc or .pdf format, not in .pages format.
Please allow 2 business days for us to contact you to setup the appointment after you submit all the necessary forms.
ATTN NON-MICHIGAN RESIDENTS: The laws permitting telemedicine outside of Michigan have changed now that the Covid emergency has ended. Michigan physicians are no longer able to treat non-Michigan residents. Michigan residency is defined as living more than 183 days (6 months) in Michigan.
***PLEASE NOTE: As of April 2024, our first available new patient appointment is 7-8 months out or more. ***
CHILDREN 12 and UNDER:
Child history form: Word document PDF document
Teacher evaluation form: Word document PDF document We require an evaluation from at least one teacher who knows the student’s capabilities well.
Teenagers 13-17:
Teen history form: Word document PDF document
Teen self-assessment: Word document PDF document
Teacher evaluation form: Word document PDF document We require an evaluation from at least one teacher who knows the student’s capabilities well.
College students ages 18-25 years old:
College history form: Word document PDF document
Parent/Observer supplement form: Word document PDF document Must be completed by someone who knows you quite well—a parent if possible, or a spouse, partner, close friend or long-time associate.
Permission to disclose confidential information to parents (PDF form) This allows Attention MD to discuss payment issues, prescription refills and/or ongoing care with parents or guardians. This is necessary when young adults are carried on their parents' insurance.
Adults 18 and older unless enrolled in college:
Adult history form: Word document PDF document
Observer supplement form: Word document PDF document A history provided by a spouse or significant other is required. If this is not possible, the forms should be completed by someone who knows the new patient quite well such as close friend or long-time associate.
Permission to disclose confidential information to parents: (PDF form) This allows Attention MD to discuss payment issues, prescription refills and/or ongoing care with a spouse or parent. This is necessary when young adults are carried on their parents' insurance or when a significant other will participate in appointment scheduling, prescription refills, etc. .
PAYMENT DETAILS
Our standard is to provide the highest possible level of care at the lowest cost.
We have chosen not to bill or participate with insurance companies and to share the savings with our patients.
We make it simple for you to submit claims to your own insurance company by providing you with fully completed HCFA 1500 insurance claim forms after each visit. When you submit the claim form to your insurance carrier, any reimbursement is sent directly to you.
Initial visit costs and details are the same regardless of whether there is a previous diagnosis available.
The initial cost of testing, preparation, and consultation/evaluation appointment is $570.
Please note that this includes both the complete evaluation and the initiation of treatment. (Some institutions that provide diagnosis do not include initial treatment in their evaluation.)
If you would like to ask your insurance company what they reimburse for our services, you can specify the following procedure codes:
Computerized neuropsychological attention testing: 96130
Physician evaluation of patient history questionnaires done prior to the visit: 96116
Initial consultation with physician (80-85 minutes): 99204