Forms & Articles

Authorizations for Release of Patient information

Cheboygan Patients- CH Authorization_for_Release_of_Patient_Information 12152017

Harbor Springs Patients- HS Authorization_for_Release_of_Patient_Information 12152017

MDVIP Patients- MDVIP Authorization_for_Release_of_Patient_Information 12152017

If you need to inquire as to the status of your outgoing records you may contact DataFile directly.

DataFile is available Monday thru Friday, 8:30 am – 6:00 pm EST, and virtually all emails and web inquiries are responded to same business day.

Registration Documents for Existing Patients

Please print and complete the six forms below for your upcoming appointment. Please arrive 15 minutes early for your appointment and bring with you your registration documents, drivers license, insurance card and your medications.

Assignment of Benefits Blank 01122018

Authorization VM blank 01122018

Exchange of Information 06062018

LTPC FACESHEET blank 01122018

Notice of Privacy Practices Blank 01122018

Release of Billing Information Blank 01122018

New Patient Registration Forms

Please print and complete the forms below for your upcoming new patient appointment. Please arrive 15 minutes early for your appointment and bring with you your registration documents, drivers license, insurance card and your medications. You may also want to scroll up to the Authorizations for Release of Patient Information and print out the form which corresponds to the location where you will be seen. This form will allow us to receive your medical records from your previous physician or provider.

LTPC NEW PATIENT FORMS

 Patient Forms

Please complete and return to: Little Traverse Primary Care, 8881 M-119 Hwy, Harbor Springs, MI 49740, fax to 231-348-2515, or you can drop the paperwork off at any LTPC branch.

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