[!] Alert:

Alcona Health Center continues to require that all patients and visitors to our healthcare campuses wear a face mask that covers their nose and mouth for their stay (unless the healthcare provider requests removal for diagnosis or treatment). Thank you for your cooperation and understanding.

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

Medical Records Release

ADULT Health History Form

PEDIATRIC Health History Form

Medical Records Release Requests

For the convenience of our patients, Alcona Health Center has partnered with HealthMark Group to support in the secure and timely delivery of patient records.  Patients may submit a request/authorization electronically via the HealthMark  Medical Records Request Portal by clicking here.

If it is your first time using this platform, you will need to create an account by providing your email address. Once logged in, you may select “Submit Request” from the menu options and enter all required fields to submit an authorization.  HealthMark will process your medical record request and provide notification via email once complete.  A complimentary copy of your record will be made available for you to download within 72 hours.

*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.*

STATUS INQUIRIES
To check the status of a previously submitted record request, please contact HealthMark Group directly 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 2020

Download Sliding Fee For Self-Employed Application 2020 Only use this long version of the form if you or someone in your household is self-employed.