New Patient Forms
Please print, fill out and return by mail (or drop off)
to the location that you will be using.
Registration and General Consent
Registro y consentimiento general
Notice of Privacy Practice
Aviso de Práctica de Privacidad
PEDIATRIC Health History Form
Formulario de Historial Medico Pediatrico
Dental School-Based Program Forms
All four forms can be filled out in advance but must be completed at least TWO WEEKS prior to the scheduled day that the Dental Program will be visiting your child’s school. Forms can be filled out digitally (link below, submissions go directly to dental team) or printed forms can be submitted to either our Alpena or Oscoda Dental locations.
For more information on the School-Based Dental Program, view our Services here.
Schools Serviced Include:
Alpena County:
Hinks Elementary, Besser Elementary, Lincoln Elementary, Wilson Elementary, Sanborn Elementary, Ella White Elementary, and Thunder Bay Jr. High School
Alcona County:
Alcona Elementary
Iosco County:
Richardson Elementary
Printable Forms
Submit forms digitally here
Do you know what dental sealants are and how your child can benefit from receiving them?
For more information on sealants, click here: Why We Recommend Dental Sealants.
Medical Records Release Requests
Alcona Health Citizens has partnered with HealthMark Group to ensure the accurate and timely completion of medical record requests.
How?
Requests may be submitted electronically to HealthMark’s Request Manager at https://requestmanager.healthmark-group.com. Once logged in, select “Submit Request” from the menu options and enter all required fields to provide an authorization directly to HealthMark. Your medical record request will be processed, and a notification will be sent via mail or email once complete and available for download.
*If you are requesting medical records from Petoskey Child Health Associates or the Community Health Center of Northern MI, be sure to include ‘Alcona Health Center’ before the name of the location.*
Any questions?
Please log in to Request Manager for status updates or to chat with support. If you have any questions, you may contact HealthMark at 800-659-4035 or status@healthmark-group.com.
Sliding-Fee Application
Please print, fill out, and return either by mail or by dropping off to the location that you will be using.
Sliding Fee Application
Descargar la solicitud de tarifa movil