Thirlby Clinic
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Some Health Insurances accepted include:

  • ASR-PPOM (Humana Gold Choice)
  • Blue Cross/Blue Shield
  • Champus
  • Medicare
  • PPOM
  • Priority Health
  • Others

  

Friendly, knowledgeable staff are here to help with your scheduling and billing concerns. All billing issues are handled onsite with electronic insurance filing.

Available Forms
Asterisked (*) forms may be completed and submitted online via our secure server. All forms may be printed, completed, and brought to your appointment. You can also fax forms to (231) 935-8868.
Tip: If you prefer typing to writing, type your answers into the form before printing.

New Patients: Please complete the New Patient Information Form, Registration Information Form, Physical Questionnaire, and Medical Records Release.

Established Patients: Prior to your annual physical exam, please complete the Physical Questionnaire.

Use the Tab key or your mouse, not the Return/Enter key, to move between each section/field. Pressing the Return/Enter key will submit the form.
Pharmacy   (all patients)
New Patient Information*   (new patients)
Registration Information*   (new patients/
current patients with insurance changes)
Physical Questionnaire*   (all patients)
Patient Satisfaction Comments*   (any patient)
Satisfaction Survey*   (any patient)
Medical Records Release   (any patient)
Bone Densitometry Questionnaire   (any patient)
X-Ray Release   (any patient)
Advanced Directives   (all patients)
Consent Form   (all patients)

Electronically submitted forms (*) will be validated and signed at the time of your visit.

By submitting an electronic form (*) you are giving consent for them to be sent across secure Internet lines.

All forms are protected under Copyright law; any unauthorized use is prohibited. For information, contact Donald Caraccio, MD at (231) 935-8956.