Welcome to Family Health Care Online

In accordance with Federal law and US Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, age, disability, religion, sex, and familial status (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call 800-795-3272 (voice), or 202-720-6382 (TDD). USDA is an equal opportunity provide and employer.

Patient Registration Forms :
The following forms are being made available for your convenience. Please feel free to print and fill out the forms below prior to your office visit. Don't forget to bring these forms to your appointment and present them to the front desk staff.

The forms below require Adobe Acrobat Reader to view. If you need to download the reader click here to get the Adobe Acrobat Reader.

Patient Registration Form
New Patient Application Form
(Form 2008 - Revised 10/20/2008)
Download

Patient Demographics / UDS Form
(Form 2004 - Revised 10/20/2008)
Download

Patient Rights and Responsibilities
(Form 2009 - Revised 10/20/2008)
Download

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.(Form 2007 - revised 10/17/2008)
Download

Notice of Privacy Practices Acknowledgement and Signature Form
(Form 2005 - revised 10/17/2008)
Download

Limited Power of Attorney
Temporary Delegation of Power By Parent/Guardian and Limited Power of Attorney For Consent To Medical Treatment Of Child/Legally Incapacitated Person (Form 2006 - revised 10/20/2008)
Download

JCAHO Accreditation and Contact Information
(form 2012 - Revised 10/11/2008)
Download

Requests for Information and Complaints:
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You may file a complaint by mailing or faxing us a written description of your complaint or by telling us about your complaint in person or over the telephone:

Bonnie Mapes
Director of Practice Operations
/ Corporate Compliance Officer

Great Lakes Family Care, Inc.
520 Cobbs Street, Cadillac MI 49601
231-876-6716 • 231-775-6521 (fax)
bmapes@trinity-health.org

Rod Cushman
IT Manager / HIPAA Security Officer
Baldwin Family Health Care, Inc.
1615 N Michigan Ave., Baldwin MI 49304
231-745-5013, Ext. 513 • 231-745-3690 (fax)
rcushman@familyhealthcare.org

Terri Vanias
Executive Assistant
Baldwin Family Health Care, Inc.
1615 N Michigan Ave., Baldwin, MI 49304
800-745-4611, Ext. 522 • 231-745-3690 (fax)
tvanias@familyhealthcare.org

If you are sending a complaint, please describe what happened and give us the dates and names of anyone involved. Please also let us know how to contact you so that we can respond to your complaint. You will not be penalized for filing a complaint.