New Patient Enrollment Form
Please start by filling out this form.
Sliding Scale Program
Our mission is to ensure that all patients and community members have 100% access to health care. To help make this possible we have created a sliding scale, which allows us to adjust visit costs depending on the patient’s eligibility for the program.
To apply for the sliding scale, contact one of our Financial Counselors and gather the following information for your appointment:
- Proof of Income for a one-month period (Paystubs, SSI, Disability, Unemployment, Pension, Child support, etc.)
- Most Recent Tax Return (Used to verify household size – Schedule C Form is required for those who are self-employed.
- DHS Eligibility Statement (If you are currently receiving aid from DHS or do NOT currently have any income.)
Baldwin Family Health Care is designated as a Federally Qualified Health Center (FQHC). An FQHC receives additional funding from the federal government to extend medical care to communities and individuals who are in an area where access to health care is needed. One requirement of this designation is for the health center to gather additional information about all of our patients to help determine if community medical needs are being met. In order for us to continue to serve our community, we request that you please take a moment to complete the following information.
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.
Family Health Care (FHC) is required by law to maintain the privacy of individually identifiable patient health information (this information is “protected health information” and is referred to herein as “PHI”). We are also required to provide patients with a Notice of Privacy Practices regarding PHI. We are required to post this Notice in a prominent place within our facility. We will only use or disclose your PHI as permitted or required by applicable state law. This Notice applies to your PHI in our possession including the medical records generated by us.
FHC understands that your health information is highly personal, and we are committed to safeguarding your privacy. Please read this Notice of Privacy Practices thoroughly. It describes how we will use and disclose your PHI. This Notice applies to the delivery of health care by FHC.
Notice Of Privacy Practices Acknowledgement Form
The Notice of Privacy Practices describes how the Facility uses and discloses your health information and the circumstances under which we must seek your written permission to do so. The Notice of Privacy Practices also describes rights you have under federal regulations called the Health Insurance Portability and Accountability Act (“HIPAA”). HIPAA requires us to provide you with the Facility’s Notice of Privacy Practices, and to obtain your written acknowledgment for receiving it.
By signing this form, you are acknowledging that the Facility provided you with its Notice of Privacy Practices; by signing, you are not agreeing or disagreeing with its content. If you do disagree, the Notice of Privacy Practices provides information about how you may address your concerns. By signing below, I acknowledge receiving the Facility’s Notice of Privacy Practices.
Limited Power Of Attorney
TEMPORARY DELEGATION OF POWER BY PARENT/GUARDIAN & LIMITED POWER OF ATTORNEY FOR CONSENT TO MEDICAL TREATMENT OF CHILD/LEGALLY INCAPACITATED PERSON
Parents/Guardians: Don’t leave your loved ones unprotected. Give your permission to a responsible adult so that Family Health Care/Great Lakes Family Care staff can treat your loved ones in the event of an unexpected nonemergent situation if you are going to be temporarily separated from your child or another person for whom you are responsible (parent, grandparent, etc.). Except in emergent situations, Family Health Care/Great Lakes Family Care personnel cannot provide unexpected nonemergent treatment for your child or legally incapacitated person in the event he or she becomes ill or injured without authorization. Your loved one’s care could be needlessly delayed while our staff attempts to contact you. With the proper consent, you assure your loved ones of immediate care should it be necessary. Fill out this limited power of attorney form and leave it with whomever will be responsible for your loved one in your absence. You are encouraged to follow the same procedure whenever you will be away from your loved one.