Welcome to Bronson Fa mily Medicine – The Groves
Office Hours and Appointments
Our office is open Monday through Friday from 7 a.m. to 6 p.m. We offer our patients same-day
appointments for illnesses, physicals and preventive care. Please call the office for an
appointment.
What
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
to Bring to You r First Appointment
Insurance cards
Photo identification
Medicine bottles or a list of the medications you are taking
Health history forms. These forms will be mailed to you. If you do not get the forms
before your visit, come to the office 15 minutes early to complete.
Canceling an Appointment
We know things happen that make it hard to keep your appointment. Call our office the day
before your appointment if you cannot make your scheduled appointment. If you don’t call and
miss appointments, or arrive late several times, we may ask you to find another doctor.
Emergency & After Hours Calls
A provider is on-call at all times to help with emergencies. If you feel your emergency is a
matter of life or death, call 911 or go to the nearest emergency room. If you have an urgent need
after hours, please call our office and you will be automatically redirected and able to talk with a
triage nurse. The nurse will help decide if you should stay at home and rest, schedule an
appointment with your provider or seek emergency care.
Bronson MyChart
Bronson MyChart is a free and secure way to look at parts of your medical record on your
computer. You can review prescriptions, send messages to your doctor or a member of our staff
and schedule routine appointments. At your next visit, ask how you can setup your MyChart
account.
Prescriptions
We will send your prescriptions to your pharmacy electronically. Controlled narcotic substances
and Attention Deficit Hyperactivity Disorder (ADHD or ADD) medicines still need a paper
prescription. This can either be sent to you in the mail or you can pick up in our office. Be sure
to ask for refill prescriptions while you are at the office so you do not run out of medicine.
We do not give prescriptions for new medicine, antibiotics or pain medicine over the phone. We
need to see you in the office before ordering these medicines.
Rev: 7/30/2015
Seeing Another Kind of Doctor
If you need a referral or authorization from our office to see another kind of doctor, please call
our office at least one week before your appointment. We will let your insurance company know
why you need to have this appointment. This will help you get the best benefit from your
insurance plan. If you do not get approval before your appointment, you may have to pay for the
visit yourself. We cannot authorize visits that have already happened.
Fees and Insurance
To find out if we participate with your insurance, visit bronsonhealth.com. You may get different
bills for lab, X-ray and other testing procedures. Billing for these services will be sent to you or
your insurance company.
Hospitalization
Our doctors only see patients at our office. If you need to go to the hospital, you will be cared for
by a doctor at that hospital. After you leave the hospital, you will see your Bronson Family
Medicine – The Groves doctor for follow-up care.
Bronson Family Medicine – The Groves
6938 Elm Valley Dr., Suite, 101
Kalamazoo, MI 49009
(269) 552-4233
Bronson Family Medicine – The Groves is located across from Bronson Athletic Club in
The Groves Business Park off 9th Street, just south of I-94 at exit 72.
For more information, visit our practice page on bronsonhealth.com
Rev: 7/30/2015
Medicare Patient Information (Part B)
Types of preventive Medicare visits:
“Welcome to Medicare Visit”
“Annual Wellness Exam”
Bronson does not offer this service at this time.
Bronson does not offer this service at this time.
*Routine Physical Exam Your healthcare provider
recommends routine physical exams. These exams offer
more than the “Annual Wellness Visits,” but they are not
covered by Medicare.
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
Cost not covered by
Medicare.
Care provided by a
provider (Dr., PA, NP,
RN)
Review your medical and social history
Record your height, weight and blood pressure
Find out your body mass index
Educate, counsel and/or refer you based on your
needs – he/she may talk to you about risk factors you
may have or screenings tests you need
 Listen to your heart and lungs
Check your eyes, ears, nose and throat
 Feel your stomach and other parts of your body
*Medicare does not cover routine physical exams. If you do not have other insurance,
you may have to pay for this visit in full.
It’s okay to ask questions.
Call your doctor’s office to learn more before your visit.
Bronson Nurse
Triage Service
Our practice is excited to provide our patients
with nurse triage services after normal
business hours and on weekends!
By simply making a phone call to our office,
you will be directed to talk with a nurse about
urgent needs. The nurse will help decide if
you should stay home and rest, schedule an
appointment with your provider or seek
emergency care. The nurse is also able to
connect you with a provider on-call from the
practice.
This is part of Bronson’s commitment to our
patients to provide the right care at the right
time in the right place.
Talk to our office staff or your provider to
learn about how this can help improve your
healthcare experience.
Give us your
cell phone
number
Text the message
“BHG” to the
number 622622
To: 622622
Message: BHG
Once you have sent the message, you will receive a text back thanking you for opting in. At this point you are all
set. If you need help at this point, text HELP to 622622 or to opt-out text STOP to 622622.
© 2011 Epic Systems Corporation. Confidential.
It’s like an express lane
for when you’re sick.
FastCare is healthcare from Bronson, but you don’t
have to be one of our patients — just someone
who wants the help without the wait.
FastCare accepts most insurances,
and your office visit co-pay applies.
Have a high deductible plan or no insurance? A FastCare visit is just $69, including basic labs.
Monday through Friday, 8:30 a.m. to 8:30 p.m.
Saturday, 9 a.m. to 6 p.m. • Sunday, 10 a.m. to 5 p.m.
Holidays, 10 a.m. to 2 p.m. (closed Christmas Day)
Last patient is seen 15 minutes prior to close.
Closed briefly between 2 to 2:30 p.m. for lunch.
Located Inside
5121 S. Westnedge Ave. • Portage
(269) 552-4212
bronsonhealth.com/fastcare
Services
Basic Lab Services
Treatments
•
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•
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•
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•
Monospots
Pregnancy test
Rapid strep
Urinalysis
More Services
•
•
Free blood pressure checks
Immunizations
and screenings also available
Allergies
Athlete’s foot
Bladder infections
Camp physicals
Cold & flu symptoms
Cold sores
Ear infections
Impetigo
Insect bites
Laryngitis
Minor burns & rashes
Minor sunburn
•
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Mononucleosis
Pharyngitis
Pink eye
Poison ivy
Ringworm
Sinus infections
Sore throat
Sports physicals
Styes
Swimmer’s ear
Upper respiratory infections
Urinary tract infections
Patients must be 18 months or older. Some age restrictions exist for select services.
Bronson Family Medicine - The Groves
6938 Elm Valley Drive Suit e 101, Kalamazoo, MI 49009
(269) 552-4233 • Fax (269) 552-4216
Geoffrey Hammond, MD • Eric Houchin, MD • Chris Unterseher, MD
Natasha Koren, MD • Alison Stoughton, NP • Teresa Kellogg, NP
Patients Personal History
Initial History and Physical Examination: __________________________ Date of Evaluation: ________________
Name: _______________________________________________________ Date of Birth: ____________________
Present Illness
Please list briefly, but as completely as possible, the health problems that concern you at this time:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Past Surgical History
Year
Surgery Type
Comments
Physician/Hospital
Past Medical History
Examples: Chronic diseases (diabetes, hypertension, asthma), Hospitalizations (pneumonia, heart failure)
Year
Diagnosis
Comments
Physician
Immunizations (Date of last Immunization):
Tetanus: ___________________ Pneumovax: ___________________ Hepatitis B: ___________________
Meningitis: ___________________ Zostavax: ___________________ Hepatitis A: ___________________
Bronson Family Medicine - The Groves
6938 Elm Valley Drive Suit e 101, Kalamazoo, MI 49009
(269) 552-4233 • Fax (269) 552-4216
Geoffrey Hammond, MD • Eric Houchin, MD • Chris Unterseher, MD
Natasha Koren, MD • Alison Stoughton, NP • Teresa Kellogg, NP
Tobacco Use
Smoking status:
Current Everyday Smoker
Types:
Ο Current Some Day Smoker
Packs/day:
Ο Former Smoker
Years:
Ο Never Smoker
Ο Passive Smoker
Ο Smoker, Current Status Unknown
Ο
Cigarettes
Ο
Pipe
Current User
Ο Former User
Ο Never Used
Ο
Snuff
Ο
Chew
Ο
Date quit:
Smokeless tobacco:
Types:
Ο
Date quit:
Alcohol Use
Ο No
Ο
Yes
Use/week:
Amount of alcohol/week:
Type:
Use/week:
Type:
Drug Use
No
Ο Yes
Ο
Sexual Activity
Yes
Ο No
Ο Not currently
Ο
Parners:
Ο
Male
Ο
Female
Birth control/protection:
Exercise type:
Frequency:
Safety
Are there guns in the home?
Ο Yes
If yes, are they locked up?
Ο No
Seat belt?
Ο Yes
Ο No
Ο Yes
Ο No
Carbon monoxide detectors in the home?
Ο Yes
Ο No
Ο
Cigar
Bronson Family Medicine - The Groves
6938 Elm Valley Drive Suit e 101, Kalamazoo, MI 49009
(269) 552-4233 • Fax (269) 552-4216
Geoffrey Hammond, MD • Eric Houchin, MD • Chris Unterseher, MD
Natasha Koren, MD • Alison Stoughton, NP • Teresa Kellogg, NP
Social History
How long at this job?
Occupation:
Martial Status (check one):
Ο Single Ο Widowed Ο Divorced
Spouse's name
Number of children
Last education level completed:
Ο Grade School Ο High School
Ο
Ο
Separated
College
Ο
Ο
Married If married, how many years?
Additional
Other areas of the U.S. or world lived in? Ο No
If yes, where and for how long?
Ο Yes
Exercise type:
Family History Worksheet
Mother Father Sister Brother Son Daughter MGM MGF PGM PGF
Anxiety disorder
Rheumatoid arthritis
Osteoarthritis
Asthma
Cancer
Diabetes
Heart failure
Hyperlipidemia
Hypertension
Migraines
Rashes/Skin problems
Seizures
Stroke
Thyroid disease
MGM=maternal grandmother MGF=maternal grandfather PGM=paternal grandmother PGF=paternal grandfather
PATIENT I NFOR MA TION & HOME MED ICATION LIST
Patient's Name:
Date of Birth:
Allergies:
_
Allergies Cont.
Reaction
Primary Physician:
Pharmacy (Include location):
to
Allergies:
List ALL Medications Below
*Include Over-the_Counter/Vitamins/Herbal Supplements
Name of Medication
Doses/Strength
How Many/How
Often
1 tablet every morning
Prescribed by
Example: Aspirin
81 mg
Dr. Roberts
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
21)
22)
23)
24)
For Your Safety, Please Update When Your Medications Change
Please bring this completed to your appointment
Prescribed for
Headaches
Rev: 6/4/15
Request for Access or Authorization for Use and Disclosure of Protected Health Information
Patient Name: _____________________________________________________________________
Last
First
MI
Date of Birth: _________________________________
Month
Day
Year
I give permission to Bronson Medical Practices to use or disclose my protected health information indicated below to
Physician to release records:
Physician/Person to receive records:
Name: ________________________________
Name: _Brsonson Family Medicine The Groves
Address: ______________________________
Address: 6938 Elm Valley Dr.______________
__
Kalamazoo, MI 49009____________________
Phone:
__
Phone: 269-552-4233
Fax:
__
Fax: 269-552-4216
Information to be released:
(Please check boxes that apply)
Discharge Summary
History and Physical Exam
Progress Notes
Lab Reports
X-Ray Reports
Medication Records
Detailed Bill
Other (specify content and dates) ______________________________________________________
Purpose of Disclosure:
Changing doctors
Consultation
Insurance or Workers’ Compensation
School
Research
At request of individual
Legal (specify) _______________________________________________________________
Other (specify) _______________________________________________________________
For my own use
Page 1 of 2
I authorize the release of health information, contained in my medical records including:
• Information regarding communicable diseases and infections, as defined by statue and Michigan
Department of Health rules, which include venereal disease, Tuberculosis, Hepatitis A, B, C,
Human Immunodeficiency Virus (HIV), HIV testing.
•
Acquired Immunodeficiency Syndrome (AIDS) and AIDS related complex (ARC).
•
Alcohol and drug abuse treatment information protected under the regulations in CFR 42, Part 2.
•
Mental health treatment records, psychological services and social services information including
communications made by me to a social worker, therapist, or psychologist.
Acknowledgement of Understanding:
• I understand this authorization will expire in one year from date signed.
•
I can cancel this authorization at any time by writing to Bronson Medical Group.
•
It will take effect on the date notified, except if action has already been taken.
•
I understand that if I release my medical record to a person or provider, they can release my
medical record. I know I need to check with them about their privacy rules.
•
I will get an abstract of my medical record unless I ask for the complete record.
•
No conditions will be placed on me if I sign this form.
Michigan law says I may have to pay for:
• Copies of my record
•
Inspection of my record
•
Written summary of findings
Bronson Medical Practices will not benefit from disclosing this information.
____________________________________________________
Signature of Patient
___________________________
Date
____________________________________________________
Parent or Personal Representative
___________________________
Date
Page 2 of 2
*9004286*
Affix Patient Label
Patient Demograp hics
Demographics – Patient Information
Last Name:
SSN:
First Name:
/
_/
Middle Name:
Sex: M / F / U
Address:
Birth Date:
/
/_
Home Phone:
Work Phone:
City:
State:
Cell Phone:
Zip:
E-Mail Address:
Other Communication
Allowed Communication:
Do Not Contact
E –mail
MyChart Signup
Mail
Needs Interpreter? Y/ N
Language:
Marital Status:
Religion:
Phone
Text
Ethnicity: Hispanic/ Not Hispanic
Race:
PCP Care Provider Information
Primary Care Physician:
Emergency Contact – In Case of Emergency, who to contact
Last Name:
First Name:
Middle Name:
Relation to Patient:
Home Phone:
Work Phone:
Cell Phone:
Patient Employment
Employer:
9004286 (11/13) Intranet
Employment Status:
Patient Demographics
(Bronson Medical Practices)
Not Employed
Page 1 of 4
Affix Patient Label
Patient Name:
Employer Address:
DOB:
Employment date:
City:
Employee ID:
State:
Zip:
Occupation:
Phone:
Fax:
Religious Affiliation
Church:
Gua rantor Accounts – If patient is over 18 years of age, see patient information
Last Name:
First Name:
Account Type: Patient/Family / Workers Comp / Auto
Sex: M/F/U
Birth Date:
/
Address:
/_
Middle Name:
SSN:
/
_/
Relation to Patient:
City:
State:
Zip:
Home Phone:
Guarantor Employer:
Employ. Status: Full Time / Part Time
Address:
City:
State:
Zip:
Phone:
Primary Coverage
Name of Coverage:
Member Relationship to Subscriber:
9004286 (11/13) Intranet
Patient Demographics
(Bronson Medical Practices)
Page 2 of 4
Affix Patient Label
Patient Name:
DOB:
Insurance ID:
Member Effective Date:
Group Number:
Group Name:
Authorization Phone:
Covered Through: Employment / Retirement
Subscriber Name:
Birth Date:
/
Employer size:
SSN:
/
_/
Sex: M/ F / U
/_
Subscribers Address
City:
State:
Zip:
Subscriber Phone:
Secondary Coverage
Name of Coverage:
Member Relationship to Subscriber:
Insurance ID:
Member Effective Date:
Group Number:
Group Name:
Authorization Phone:
Covered Through: Employment / Retirement
Subscriber Name:
Birth Date:
/
Subscribers Address
SSN:
Employer size:
/
_/
Sex: M/ F / U
/_
City:
State:
Zip:
Subscriber Phone:
9004286 (11/13) Intranet
Patient Demographics
(Bronson Medical Practices)
Page 3 of 4
Affix Patient Label
Patient Name:
DOB:
Visit Specific Information
Reason for Visit:
Accident Related: Y / N
Accident Date:
Accident Type:
Body Part Injured:
If Yes, Fill out Accident Information below
Accident Time:
Place of Injury: Home / Work / Other
Accident Description:
Referring Physician (if applicable):
MRN
CSN
9004286 (11/13) Intranet
Patient Demographics
(Bronson Medical Practices)
Page 4 of 4