Welcome to Pillar! This New Patient Packet is for both primary care and recovery care patients. It takes about 15 to 20 minutes, and nothing is sent until you reach the end and press Submit. You will see a confirmation screen once it is submitted.

Please have your photo ID and insurance card ready.

This form should be completed by the patient or by someone with the legal right to sign for them (a legal guardian or medical power of attorney). Pillar cares for adults 18 and older.

Disclaimer and Financial Agreement

Each licensed practitioner at Pillar provides care within the scope of their own professional license.

I accept financial responsibility for the services I receive and agree to pay at the time of service, unless other arrangements have been made with my insurance or with Pillar. I understand that a missed appointment, or a cancellation with less than 24 hours' notice, may be charged the fee listed in the Patient Fees and Payment Agreement, and that a $50.00 fee may be added if my account must be sent to collections.

Recording. To protect everyone's privacy, patients and visitors may not record visits (audio or video) without the provider's written permission. Pillar records visits only with your permission, as described in the AI Note-Taking Assistant section of this packet.

By signing below, I acknowledge that I have read and agree to these terms.

I authorize Pillar to bill my insurance companies for my care and to release to them the information needed to process my claims. I authorize direct payment of insurance benefits to Pillar, and I authorize Pillar to act as my agent in obtaining payment from my insurance. I understand that I am responsible for my bill, including cash-pay amounts, deductibles, copays and the late cancellation and no-show fees described in this packet. I authorize billing for telehealth visits.

I consent to medical treatment by Pillar providers, including telehealth and in-person services. A copy of this authorization may be used in place of the original.

For recovery care patients, release of substance use disorder records to insurance is covered by the separate 42 CFR Part 2 consent in this packet.

Language assistance and accessibility: free interpreters, translated materials and other aids are available to you. Ask our staff or call (517) 225-4483.

Atención: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (517) 225-4483.

ملحوظة: إذا كنت تتحدث العربية، فإن خدمات المساعدة اللغوية تتوفر لك بالمجان. اتصل برقم (517) 225-4483.

Signature below acknowledges receipt of the HIPAA Notice of Privacy Practices and the Notice of Nondiscrimination above, and, for recovery care patients, the Controlled Substance Agreement.

It is your responsibility to know your insurance policy. Many policies have exclusions, and most have deductibles, copays and coinsurance. Some policies may not cover our services, including telehealth. Please check with your insurance company whether your provider is "in network"; if not, your costs may be higher. Regardless of insurance coverage, you are responsible for charges your insurance does not pay. Unpaid balances are handled as described in the Patient Fees and Payment Agreement.

Many patients allow family members, such as a spouse or parent, to call and ask about their care or bill. Under HIPAA, we cannot share this information without your written permission. If you would like us to share your medical and/or billing information with family members, list them below. We will share information only with the people you name.

Purpose: at my request, to involve the people named below in my care and billing. Expiration: this authorization expires one year from the date I sign it, unless I revoke it sooner. I may revoke it at any time by telling Pillar in writing; revoking does not affect information already shared. Signing is voluntary, and my treatment, payment, enrollment or eligibility for benefits will not depend on whether I sign. I have the right to inspect or get a copy of the information to be shared.

Information shared under this authorization may be shared again by the person who receives it and may no longer be protected by HIPAA. However, substance use disorder records protected by federal law (42 CFR Part 2) may not be shared again except as Part 2 allows.

I authorize Pillar to release my medical and/or billing information to the following individual(s):

At Pillar we are committed to providing you with high-quality health care. To ensure a smooth and efficient payment process, we have certain financial procedures in place. Please take note of the following information:

We bill usual and customary fees for standard services offered.

Additional services not covered by insurance companies include:

1. FMLA, long term medical leave/extensive forms: $50.00
2. Short medical leave, short-term leave forms: $25.00
3. Late cancel without a 24-hour notice or No-show fee: $50.00
4. Returned check fee: $35.00
5. Medical record copying will be charged according to State Law rates.

I understand payment for services is due at the time the services are rendered. I understand deductibles and co-pays applicable to my policy is best explained by my insurance provider, but is the responsibility of the patient.

Credit Card Information: Pillar may require patients to provide credit card information prior to their appointment. This is to ensure that any deductibles determined by your insurance can be covered at the time of your appointment if necessary. Card details are never collected on this form; they are stored only in our secure payment system.
Payment Options: We offer various payment options for your convenience. You have the choice to pay via:

1. Credit Card: Your credit card on file will be charged for any applicable deductibles determined by your insurance at the time of your appointment.
2. Cash: You may pay in cash if that is your preferred method of payment. Please inform the office staff if you intend to pay in cash.
3. Check: If you prefer to pay by check, please let our staff know in advance, and arrangements will be made to accept your payment.
4. Other Digital Payment Methods: We understand that you may have other digital payment preferences. If you wish to use an alternative digital payment method, please notify the office staff in advance so that necessary arrangements can be made.

I understand that Pillar reserves the right to use an outside collection agency as a means of collecting any outstanding balances, if my account remains unpaid or payment arrangements are not made. I understand that if my account goes to collections, I will be charged an additional $50.00.

I understand it is my responsibility to keep scheduled appointments or notify the office staff 24 hours prior to the scheduled appointment time or be charged a $50.00 no show fee. This fee is due at the next scheduled appointment and cannot be billed to your insurance carrier.

Fees are subject to change without notice.

For patients not utilizing insurance, usual and customary fees set forth by Pillar apply unless a different rate has otherwise been specified. Good Faith Estimate: if you do not have health insurance or are not using insurance, you have the right to receive a Good Faith Estimate of the expected charges for your care. Ask our staff, or visit www.pillarprimary.com/good-faith-estimate.

By signing below, I acknowledge that I have read, understand, and agree with the financial conditions described above. I understand that Pillar may require my credit card information and that I have the option to choose my preferred payment method.

Notice: if a patient balance exceeds $200.00 and no payment plan or partial payment has been made, future appointments may be rescheduled until a payment plan is in place. Pillar will contact you at least 3 times by text and phone about your options before any appointment is rescheduled. Pillar will not stop a medically necessary medication without a safe plan for your care, such as a short bridge prescription, a taper, or a referral to another provider.

Telehealth means a visit with a Pillar provider by secure video or, when appropriate, by phone, instead of in person. It may be used for both primary care and recovery care.

Benefits: easier access to care and less travel. Risks: technical problems can interrupt a visit; a telehealth visit may not be as complete as an in-person visit; and despite our security measures, electronic information could be accessed by unauthorized people. Pillar uses secure, HIPAA-compliant software.

Your provider decides whether telehealth is right for your visit and may ask you to come in person. Some medications, including certain controlled medications, may require in-person visits under federal (DEA) and Michigan rules. The same privacy protections apply to telehealth as to in-person care, including the legal exceptions for reporting abuse or threats of harm. You may ask for an in-person visit instead at any time.

Your responsibilities: join from a private place; tell your provider if anyone else can see or hear the visit; do not record the visit without your provider's written permission; and make sure your device and internet connection work before the visit. Please check with your insurance whether telehealth is covered; if it is not, you are responsible for the cost.

By signing below, I consent to telehealth services with Pillar. I understand I can withdraw this consent at any time.

Pillar providers may use Sully.AI, a secure artificial intelligence (AI) assistant, to help write visit notes. With your permission, it listens to and records the conversation during your visit, in person or by telehealth, and creates a draft note. Your provider reviews and edits every note before it becomes part of your medical record; the assistant does not make treatment decisions.

Sully.AI works for Pillar under a Business Associate Agreement and must protect your information under HIPAA and, for recovery care, 42 CFR Part 2. Recordings are kept only as long as needed to create your note, under Pillar's records policy.

You may say no now, or at any visit, and you can ask your provider to stop the recording at any time. Saying no will not affect your care in any way.