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.
- Phone: 816-437-9134
- Email: status@DataFileTechnologies.com
- web: https://www.datafiletechnologies.com
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
Notice of Privacy Practices Blank 01122018
Release of Billing Information Blank 01122018
Request To Establish Care Form
Please print form and read the letter carefully. If you are interested in becoming a new patient please complete the form on the third page and return it to the front desk in the Harbor Springs office or fax to 231-347-2020.
HS Request To Establish Care Form
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.
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.
- Authorization VM blank 01122018 Please complete if you would like LTPC to be able to leave detailed voicemail messages with non-critical health information
- Exchange of Information 01122018 – Please complete if you want someone else (i.e. family member) to be able to communicate with us regarding your healthcare
- Authorization-to-treat-minors – Please complete to authorize the evaluation and/or treatment of a patient under the age of 18
- Authorization-to-treat-minors-multiple-visits – Please complete to authorize the evaluation and/or treatment of a patient under the age of 18 for multiple future visits
- Appointment of Agent for Minor Child – Please complete to authorize an individual to act as an agent for the care of a minor child
- Living-will-appointment-of-healthcare-surrogate – Please complete and return to Little Traverse Primary Care – no notary needed
Worker’s Compensation Forms
- Employer Work Comp Form – Please complete to authorize us to send your health information to your employer for worker’s compensation purposes
- Worker’s Compensation Authorization Form