New Horizons Medical Center, P.C.

19335 Merriman Road
Livonia, MI 48152

Hours: Monday – Friday
8:00 am – 5:00 pm
By Appointment

Phone: 248.474.4900
Fax: 248.474.3278

Acknowledgement of Receipt of Notice of Privacy Practices

Your name and signature on this sheet indicate that you have received a copy of the New Horizons Medical Center Notice of Privacy Practices on the date indicated. If you have any questions regarding the information in the NHMC Notice of Privacy Practices, please ask to speak with a clinic representative as indicated in your Notice.

HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used
and disclosed and how you can get access to this information.

Medical Record Authorization

To request a copy of your New Horizons medical records, simply download, print, complete and sign the following authorization forms.

Patient Contact Information

For any new patient, or patient that may need to update and/or change your personal information, please print this form and fill it out. Please bring it with you to our office.

Patient Pharmacy Form

Prescriptions for mail away pharmacies can be picked up at the Front Desk on the next business day after refill request.

Patient Record of Disclosures

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

Patient History Form

For any new patient, please print this two page form, complete the health history questionnaire and bring it with you to our office.