Forms & Articles
Authorizations for Release of Patient information
Cheboygan / Dr. Drogowski Patients transferring to Alcona Cheboygan Campus- Authorization for Release of Patient Information to Alcona CH
Cheboygan Patients- CH Authorization For Release of Patient Information
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 (ScanSTAT) directly.
DataFile (ScanSTAT) 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: firstname.lastname@example.org
- web: https://www.scanstat.com/check-records-request-status/
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.
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 (Single Visit) – Please complete to authorize the evaluation and/or treatment of a patient under the age of 18
- Authorization to Treat Minors (Multi Visit) – 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