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
ADULT Health History Form
Formulario de historial de salud para adultos
PEDIATRIC Health History Form
Formulario de Historial Medico Pediatrico
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.
Behavior Health Forms
Please refer to the Locations page for the appropriate form.
Sliding Fee Application
Please print, fill out, and return either by mail or by dropping off to the location that you will be using.
Download Sliding Fee Application
Descargar la solicitud de tarifa movil