Welcome and thank you for choosing the Grand Traverse Band Health Services for your (2025)

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Dear New Clients,

Welcome and thank you for choosing the Grand Traverse Band Health Services for your

health care needs. We are dedicated to providing you with the best quality care possible.

For new clients, the following documents are REQUIRED before scheduling a visit with GTB

health services.

Registration- MUST be ﬁlled out completely.

Valid TRIBAL identiﬁcation card from a federally recognized tribe- MUST be up to date.

Valid Driver’s License/State ID.

Any active insurance card(s) you have.

Any legal documents relevant to patient care:

•

Legal guardianship, adoption, or foster care.

Power of attorney related to medical services.

Signed Release of Records Form- if you have/had a previous primary care provider.

Two residency veriﬁcation documents- current physical address only:

•

Drivers License;

State ID;

Voter Registration Card;

Lease Agreement;

Vehicle Title;

Envelope postmarked within the past 90 days. (including enrollee’s name)

Once we receive your registration and all required documents, we will get you registered

into our system, this process can take 24-48 hours. Our scheduler will contact you for an

appointment.

ATTENTION:

INCOMPLETE REGISTRATION WILL NOT BE ACCEPTED – WE NEED ALL DOCUMENTS.

GRAND TRAVERSE BAND FAMILY HEALTH SERVICES

First Name: __________________ Last Name: _________________ Middle: ___________ Preferred Name: __________

Date of Birth: ________________ Social Security Number: ______________________ Religion: _____________ Sex: M | F

Gender Identity: ________ Pronouns: _________ Marital Status: Single | Married | Divorced | Separated | Widow/er

Tribe: ___________________ Enrolled: Y | N Enrollment Number: ______ Ethnicity: Hispanic|non-Hispanic|Unknown

City of Birth: ___________________ State of Birth:________ Preferred Language: English | Spanish | Interpreter | Other

Physical Address: _________________________________________________________________________________________

Street

City

State

Zip

Mailing Address: __________________________________________________________________________________________

Street

City

State

Zip

Main Phone Number: ___________________ ALT number: _________________ Work Number: _______________________

Do you have health/dental insurance: Y | N Insurance provider/s: ______________________________________________

E-mail address:____________________________________________________________________________________________

Spouse Employer: ___________________________________________________ Work Number:________________________

Father’s Name: __________________________________________ City of Birth: ________________ State:______________

Mother’s Name: _________________________________________ City of Birth: ________________ State: ______________

Emergency Contact: _______________________________________________________________________________________

Name

Phone Number

Relationship

Emergency Contacts Address: _____________________________________________________________________________

Street

City

State

Zip

Next of Kin: _______________________________________________________________________________________________

Name

Phone Number

Relationship

Next of Kin Address:_______________________________________________________________________________________

Street

City

State

Zip

How would you like GTB services to contact you about your appointments: MAIN PHONE | EMAIL | TEXT

MILITARY SERVICE

Veteran: Y | N Last Entry Date: ________________ Service Separation Date: ___________

Vietnam Duty: Y | N Service Connected: Y | N

Claim Number: ______________

HRN_____

Initial_____

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 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 / Donefos / 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 currently? 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 and is only for the sue in treatment, billing, and

processing of insurance for benefits for 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 the benefits otherwise

payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. 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 Health Services

CLIENT RELEASES

AUTHORIZATION TO RELEASE HEALTH INFORMATION

AND ASSIGNMENT OF BENEFITS

I authorize releasing any or all my Personal Health Information (PHI), 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.

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 Health Department and Behavioral

Health Services. By Signing this, I understand that any or all information in my medical records may be

released, not excluding substance abuse, mental health, HIV/AIDS, STDs, etc.

RIGHTS AND RESPONSIBILITIES

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

______________________________ _______________________________ ______________

Print Name

Signature

Date

HRN: _________

INITIALS: _______

Grand Traverse Band Health Services

NON-GTB/ NON-NATIVE CLIENT 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 billable 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-Native member of an eligible Native’s household may be seen at the GTB Clinic, Dental 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 MEDICAL INFORMATION AND ASSIGNMENT OF BENEFITS

I authorize releasing any or all my Personal Health Information (PHI), 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.

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 Health Department. By Signing this, I understand that any

or all information in my medical records may be released, not excluding substance abuse, mental health,

HIV/AIDS, STDs, etc.

RIGHTS AND RESPONSIBILITIES

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

______________________________________

Print Name

________________________________________

Signature

____________

Date

HRN: _______

INITIALS: _______

We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties

and privacy practices with respect to your PHI.

This notice is effective as of April 14, 2003 and we are required to abide by the terms of this Notice of Privacy

Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to

make the new notice provisions effective for all PHI that we maintain. If we have made any changes to the

Notice of Privacy on an annual basis.

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

privacy rights. You may file a complaint with us by notifying our Privacy Officer in writing 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 Health Services at telephone (231)534-7200

number or toll-free (866)-534-7750 ext.7200, or in writing at:

Please contact us for more information:

For Information about HIPAA:

HIPAA Privacy Compliance Office

Grand Traverse Band Health Department

2300 N Stallman Rd, Suite A

Peshawbestown, Michigan 49682

The U.S. Department of Health & Human Services

Office of Civil Rights

200 Independence Avenue, SW

Washington, D.C. 20201

(202) 619-0527 Toll Free: 1-877-696-6775

PLEASE COMPLETE AND SIGN

Name:_________________________________________________________________________

Address:_______________________________________________________________________

_______________________________________________________________________

Birth Date:______________________________ Phone Number:_________________________

I HAVE READ AND AKNOWLEDGE RECEIPT OF THE GRAND TRAVERSE HEALTH SERVICES

NOTICE OF PRIVACY PRACTICES

__________________________________________

Signature

_______________________

Date

HRN:_________

INITIALS:_________

Grand Traverse Band Health Services

NO-SHOW/CANCELLATION POLICY

To ensure effective patient care, it is important to keep scheduled appointments. Missing an

appointment without notice delays your treatment and prevents other patients from receiving

care during that time slot. If you need to cancel or reschedule, please notify us at least 24 hours

in advance. Failure to do so will be considered a “no-show.”

DENTAL PATIENTS who accumulate three or more no-shows within a 3-month period

may only be seen on a walk-in basis as time permits. Additionally, some dental treatments must

follow a specific sequence, and canceling or missing an appointment may impact subsequent

visits.

As a courtesy, our offices will attempt to remind you of your appointment 1 to 2 days prior.

Appointment reminders will be left via voicemail or text message at the phone number on file.

Please note that if your phone service is disconnected or unable to receive voicemails, you risk

automatic cancellation of future appointments.

WALK-IN POLICY

Pa�ents seeking non-emergent medical services during regular oﬃce hours may be seen as

walk-ins. However, wait �mes may be longer compared to scheduled appointments. In the case

of a true dental emergency, we will priori�ze scheduling you as soon as possible.

LATE POLICY

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

reschedule your visit, and your appointment will be recorded as a “no-show.”

__________________________________

Print Name

________________________________

Signature

___________

Date

HRN: _________

INITIALS: _________

Grand Traverse Band Health Services

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 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 make

revoke your consent in writing, and we are required to honor and abide by that written request, except for 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.

CLIENT RIGHTS AND RESPONSIBILITIES

The Grand Traverse Band (GTB) Health Department is committed to providing you with caring, quality

services. As a client you have specific rights and responsibilities

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.

• To participate actively in determining a course of treatment for yourself.

• To 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.

• To refuse treatment, be told what effect this may have on your health and have information on

the other potential consequences of refusal.

• To request a second opinion from another physician.

• To receive considerate and respectful care in a clean and safe environment.

• To know by name the physicians, nurses, and other staff members responsible for your care.

• To be notified of any medical research or educational projects that may affect your care.

• To refuse to take part in any research or educational projects.

• To have privacy while in the clinic, and confidentiality of all information and records regarding

your care.

• To designate an individual to represent you in making decisions regarding your treatment and

healthcare.

• To be provided with complete information about the clinic’s policies regarding patient rights,

patient complaints, and advance directives.

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

feel secure while receiving services. Your cooperation in following through with these responsibilities will

help us provide you and others with quality services.

You are Responsible:

• To confirm scheduled visits and appointments by responding to confirmation calls/texts.

• To keep contact information such as phone numbers and addresses up to date.

• To come to all appointments with your correct and current insurance cards and tribal ID.

• To cooperate with your caregivers and follow the plan of care you, your physician, and your

health care team have agreed upon.

• To please try to understand and follow instructions concerning your treatment and ask questions

if you do not understand or need further explanation. Your overall health is important.

• To respect the privacy and confidentiality of other patients.

• To cooperate with all people providing you with care.

• Respect the property and the environment.

• To inform outside providers (e.g. urgent care, emergency room, and referral offices) of the clinic’s

name, your primary care provider, and our fax number to ensure all records are sent to us. This

will help us provide you with quality care in a timely manner. Our fax number is 231-534-7460.

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

complaint, you may contact the Health Administrator at 231-534-7200.

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.