GRAND TRAVERSE BAND FAMILY HEALTH CLINIC

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Last Name________________ FirstName______________ Middle__________

Birth Date: ________________ Social Security Number__________________ Sex: M F

Tribe:________________ Enrolled: Y N Enrollment Number:_____________

Are you: Married Single Divorced Widowed?

Telephone Number: ___________________

Work Number: __________________

Employer: _______________________________ Full Time Part Time Seasonal

Medical and Dental Insurance

(If you do not have Medical or Dental Insurance, please put “NONE” in the spaces below)

Medical insurance Primary Carrier

Insured’s name ______________________________

Medical insurance secondary Carrier

Insured’s name ______________________________

Social security #______________________________

Insurance company___________________________

Address ____________________________________

City _____________state ________Zip ___________

Group # _____________ID# ____________________

Birthday____________________________________

Insured’s Employer ___________________________

Dental insurance Primary Carrier

Insured’s name ______________________________

Dental insurance Secondary Carrier

Insured’s name ______________________________

Social security #______________________________

Insurance company___________________________

Address ____________________________________

City _____________state ________Zip ___________

Group # _____________ID# ____________________

Birthday____________________________________

Insured’s Employer ___________________________

MEDICAL HISTORY UPDATE

PATIENT NAME:

Physician’s name: ____________________________________________ Physician’s ph.# __________________________

Date of last physical: _____________________

DO YOU OR HAVE YOU HAD ANY OF THE FOLLOWING:

Circle any and explain in the next section:

Heart Disease or Attack

Allergies to Anesthetics

History of Bulimia

Nervous Problems

Heart Murmur

Contact Lenses

Kidney Problem

Rheumatic Fever

Heart Pacemaker

Hypoglycemia

Thyroid Disease

Psychiatric Care

Angina Pectoris

Artificial Heart V

Glaucoma

Allergy to Latex

Mitral Valve Prolapse

Artificial Joints

Diabetes

AIDS/HIV Positive

High Blood Pressure

Recent Weight Loss

Arthritis/Rheumatism

Venereal Disease

Low Blood Pressure

General Allergies

Allergy to Dyes

Cancer/Leukemia

Circulatory Problems

Blood Disease

Special Diet

Hemophilia

Asthma

Back Problems

Swollen Neck Glands

Blood Transfusion

Hepatitis/Jaundice

Sinus Problems

Ulcer

Tuberculosis

Liver Disease

Stroke

Respiratory Problems

Tobacco Use

Epilepsy/Seizures

Headaches

Chemical Dependency

Chronic Bleeding Gums

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1) Do you take, or have you taken, any of the following medications for Osteoporosis or Bone Cancer? Please circle if YES.

-- Actonel / Boniva / Fosamax / Fosamax plus D / Aredia / Denosumab (Prolia, Xgeva) / Zometa / Reclast -2) Do you have any drug allergies, or have you ever had an adverse reaction to any medication or substance? If YES, please list.

_________________________________________________________________________________________________________________

3) Have you ever responded adversely to medical or dental treatment? ______________________________________________________

4) Are you taking any medication at this time? Please list: ________________________________________________________________

_________________________________________________________________________________________________________________

5) Have you ever taken Phen-Fen (diet drug)? Please circle YES or NO

If YES, have you seen a cardiologist for a consult since taking it? Please circle YES or NO

6) Are you under the care of a physician for anything other than regular check-ups? Please circle YES or NO

If YES, for what condition?__________________________________________________________________________________________

7) WOMEN: Are you pregnant, nursing, taking birth control, or had a recent transfusion? Please circle any that apply.

8) Is there anything else we should know about your medical history? _______________________________________________________

Authorization and Release:

The above information is accurate and complete to the best of my knowledge. It is only for the treatment, billing, and processing of

insurance for benefits to which I am entitled. I authorize the dentist to release any information, including the diagnosis and the records

of any treatment for examination rendered to me or my child during the period of such dental care, to third-party payers and/or other

health practitioners. I authorize my insurance company to pay directly to the dental office for the benefits otherwise payable to me. I

understand that my dental insurance carrier may pay less than the service bill. I agree to be responsible for payment of all services

rendered on my behalf or my dependents.

Signature of patient or parent if minor: ________________________________________________ Date: ______________

Grand Traverse Band Family Health Clinic

Non-GTB/ Non-Native Employee/Non-Native Spouse Medical Releases

FINANCIAL POLICY

Our billing department will send a medical claim to your insurance company for the services you received

here. We do take part with most insurance companies. You will, however, be financially responsible for the full

payment of your co-pay before receiving services not covered by your insurance policy.

I understand I am Financially responsible for full payment of my co-pay before receiving services and for all

deductibles not covered by your insurance policy.

*A non-Indian member of an eligible Indian's household may be seen at the GTB Clinic when it has been

determined, in consultation with the Health Administrator, that services are necessary to control a public

health hazard or an acute infectious disease, as stated in 42 C.F.R. § 136.12(a).

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

I authorize releasing any or all my Personal Health Information, including the diagnosis and records necessary

to complete all insurance claims. This release is solely for billing and reimbursement directly to Grand Traverse

Band Family Health Clinic for any benefits I am entitled to.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Based on the Privacy Act of 1974, P.L. 93.579, I authorize the release of my medical information for referrals to

health providers outside the Grand Traverse Band Family Health Clinic. By Signing this, I understand that any

or all information in my medical records may be released, not excluding medical information related to

substance abuse, mental health, HIV/IDA, STDs, etc.

RIGHTS AND RESPONSIBILITIES

I have read and acknowledge receipt of the Patient Rights and Responsibilities statement.

SIGNATURE: __________________________________ DATE: _______________________

Revised 11/23 CAM

HRN: _______

INITIALS: _______

Grand Traverse Band Family Health Clinic

2024 Client Releases

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

I authorize releasing any or all my Personal Health Information, including the diagnosis and records

necessary to complete all insurance claims. This release is solely for billing and reimbursement directly

to Grand Traverse Band Family Health Clinic for any benefits I am entitled to.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Based on the Privacy Act of 1974, P.L. 93.579, I authorize the release of my medical information for

referrals to health providers outside the Grand Traverse Band Family Health Clinic. By Signing this, I

understand that any or all information in my medical records may be released, not excluding medical

information related to substance abuse, mental health, HIV/IDA, STDs, etc.

RIGHTS AND RESPONSIBILITIES

I have read and acknowledge receipt of the Patient Rights and Responsibilities statement.

SIGNATURE: __________________________________ DATE: _______________________

REVISED 11/23 CAM

Pg.5

HRN: _________

INITIALS: _______

NO-SHOW CANCELLATION POLICY

It is essential for the care of our patients that appointment times be kept as scheduled. By not

showing up for your appointment as planned, you are not only delaying and avoiding your dental or

health care but also occupying a time slot that could have been used for another patient’s care. For this

reason, we ask that if you are going to miss a scheduled appointment, please call us 24 hours in advance

to reschedule. Failure to do so will constitute a “NO-SHOW” appointment. If you "NO-SHOW" for three

or more appointments within a 3-month period, you will be seen as time allows.

The GTB Family Health and Dental Clinics will provide a courtesy reminder call for appointments

approximately 1 to 2 days in advance. We will leave an appointment reminder voicemail with the phone

number on file. However, suppose your phone has been disconnected or unable to accept voicemail

messages. In that case, it can result in automatic cancellations for all GTB Dental Clinic appointments if

you do not keep your scheduled appointment. Please be aware that some Dental appointments must be

completed in a specific order, and if you cancel/no-show one appointment, it could also affect others.

WALK-IN POLICY

If you need non-emergent medical services during regular office hours, you may be seen as a

walk-in patient without an appointment. Since you are being worked in, your wait may be longer than

those patients with scheduled appointments. If you have a true dental emergency, you will then be

scheduled as soon as possible.

LATE POLICY

If you are more than 10 minutes late for your scheduled appointment, we reserve the right to

reschedule, and you will be considered a “NO-SHOW.”

_____________________ __________________________________ _________________

Printed Name

CAM 11/2023

Signature

Date

Pg. 4

HRN: ______

INITIAL: ______

Grand Traverse Band Family Health Clinic

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We at the Grand Traverse Band Family Health Clinic are legally required to maintain the privacy of individually

identifiable health information, as required by the Federal Health Insurance Portability Act (HIPAA) of 1996. This notice

describes how medical information about you may be used and how you can get access to this information. This

protected health information is referred to as “PHI.” We are also required to provide patients with a Notice of Privacy

Practices permitted or required to post this Notice in a prominent place in our facility; we will only disclose your PHI as

permitted or required by applicable state law. Federal and state laws further restrict the uses and disclosers of your

mental health, substance abuse, and infectious disease information. This Notice applies to your PHI in our possession,

including the medical records we generated.

As required by “HIPAA,” we have prepared this explanation of how we are required to maintain the privacy of your

health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment, and

operations.

•

TREATMENT means providing, coordinating, or managing health care and related services by one or more providers.

An example of this would include a physical examination.

PAYMENT means obtaining service reimbursement, confirming coverage, billing or collection activities, and

unitization review. An example of this would be sending a bill for your visit to your insurance company for payment.

OPERATIONS include the business aspects of running our practice, such as conducting quality assessment and

improvement activities and utilization review. An example of this would be an internal quality assessment review.

We may also create and distribute unidentified health information by removing all references to

individually identifiable information.

Other uses and disclosures will be made only with written authorization. You may revoke your

consent in writing, and we are required to honor and abode by that written request, except for the

the extent that we have already taken actions relying on your authorization.

You have the following rights concerning your PHI, which you can exercise by presenting a written request to the Privacy

Officer:

• The right to request restrictions on specific uses and disclosures of PHI, including those related to disclosures to

family members, other relatives, closer personal friends, or any other person identified by you. We are, however,

not required to agree to a request restriction. If we decide on a limitation, we must abide by it unless you agree in

writing to remove it.

• The right to reasonable requests to receive confidential communications of PHI from us by alternative means or

locations.

• The right to inspect and copy our PHI.

• The right to amend your PHI.

• The right to receive an accounting of disclosures of your PHI.

• The right to obtain a paper copy of this notice upon request.

Revised 11/2023 CAM

We are required by law to maintain your PHI's privacy and provide you with no�ce of our legal du�es

and privacy prac�ces concerning your PHI.

We must abide by the terms of this No�ce of Privacy Prac�ces currently in eﬀect. We reserve the right to

change the terms of our No�ce of Privacy Prac�ces and make the new no�ce provisions eﬀec�ve for all

PHI we maintain if we have made any changes to the No�ce of Privacy on an annual basis.

You may complain to us or the Secretary of Health and Human Services if you believe we have violated

your privacy rights. You may ﬁle a complaint with us by no�fying our Privacy Oﬃcer in wri�ng of your

complaint. Please use the Grand Traverse Band Family Health Clinic complaint form. We will not retaliate

against you for ﬁling a complaint.

You may contact our Privacy Oﬃcer at the Grand Traverse Band Family Health Clinic at (231)534-7478 or

toll-free (866)-534-7750 ext.7478.

Don't hesitate to get in touch with us for more

informa�on:

HIPAA Privacy Compliance Oﬃce

Atn: Judy Stot

2300 N Stallman Rd, Suite A

Peshawbestown, Michigan 49682

(231) 534-7478

Informa�on about HIPAA:

The U.S. Department of Health & Human Services

Oﬃce of Civil right

200 Independence Avenue, SW

Washington, D.C. 20201

(202) 619-0527

Toll Free: 1-877-696-6775

For Clinic Use Only

Policy Handed to Pa�ent

Pa�ent Not Present.

The policy sent to Pa�ent

Refused

REVISED CAM 11/2023

Pg. 3

HRN: _______

INITIALS: ________

Patient Rights and Responsibilities

Your rights

As a client of the Grand Traverse Band Family Health Clinic, Dental Clinic, and PRC you have

the right to:

•

Receive complete and current information about your diagnosis, treatment, and prognosis in terms you

can be reasonably expected to understand.

Participate actively in determining a course of treatment for yourself.

Receive information you need to give informed consent for any proposed treatment procedures, including

information about the risks, benefits, and alternatives to the proposed procedure or treatment.

Refuse treatment, be told what effect this may have on your health, and have information on the other

potential consequences of refusal.

Request a second opinion from another physician.

Receive considerate and respectful care in a clean and safe environment.

Know by name the physicians, nurses, and other staff members responsible for your care.

Be notified of any medical research or educational projects that may affect your care.

Refuse to take part in any research or educational projects.

Have privacy while in the clinic, and confidentiality of all information and records regarding your care.

Designate an individual to represent you in making decisions regarding your treatment and healthcare.

Be provided with complete information about the clinic’s policies regarding patient rights, patient

complaints, and advance directives.

Your Responsibilities

Rules and regulations regarding conduct are necessary to ensure that all patients are

treated fairly and feel secure while being clients at the clinic or receiving services through

Contract Health. Your cooperation in these responsibilities will help us provide quality care

and service. Please…

•

Cooperate with caregivers and follow the plan of care you, your physician, and your health care team have

agreed upon.

Ask questions of your caregivers, and communicate any concerns or wishes you may have,

Respect the privacy and confidentiality of other patients.

If you have any questions about your rights, need more information, or have a complaint,

please get in touch with the Health Administrative Assistant at 231-534-7200.

Revised 2023 AA

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.