[!] Alert:

Masks covering the nose and mouth are required to be worn on all of our campuses. Thank you for your cooperation.

Forms

New Patient Forms – Please print, fill out and return by mail (or drop off) to the location that you will be using.

 

Alcona Health Center’s Registration form and Financial Policies  Formulario de Inscripción a Centros de Salud Alcona y Políticas Financieras

Notice of Privacy Practice  Aviso de Práctica de Privacidad

Medical Records Release

ADULT Health History Form

PEDIATRIC Health History Form

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.

FMLA and Disability Paperwork Requests

Alcona Health Center has partnered with HealthMark Group to ensure the accurate and timely completion of your FMLA and/or Disability forms. You will still present these forms at your healthcare provider’s office as before.  However, a signed and completed authorization form will be required from each patient and then paperwork and forms of these types will be submitted to the HealthMark Group.  Each form requested for completion will require a $35 fee to be paid directly to HealthMark Group. HealthMark Group will complete the forms upon receipt of the requested forms and a valid authorization. The estimated turnaround time will be 24-72 hours. If an email is provided, you will receive a response directly from HealthMark Group notifying you of the prepayment invoice. After payment, the completed forms may be downloaded directly through HealthMark Group’s website, or provided directly to you through an agreed to delivery method (i.e. secure email, mail, etc.)  If you would like to inquire on the status of your forms or have any additional questions, please call 972-895-2138 or email fmla@healthmark-group.com

School Based Location Forms – Please print, fill out and return by mail (or drop off) to the location.

Tiger Health Extension Consent Form

 

Sliding Fee Application – Please print, fill out and return by mail (or drop off) to the location that you will be using. 

Sliding Fee Supporting Documents

Download Sliding Fee Application 2022  Descargar la solicitud de tarifa movil 2022

Download Sliding Fee For Self-Employed Application 2022  Descargar la tarifa movil para la solicitud de autonomos 2022

Only use this long version of the form if you or someone in your household is self-employed.