Forms

 

 

Frequently requested patient forms and brochures are below for your convenience. Additional information is available at your Upper Great Lakes Family Health Center.

Patient Forms

Authorization to Accompany Minor to Appointment

Release of Information – General

Release of Information – Behavioral Health Consent to Share

Informational Brochures

Patient Rights & Responsibilities

Patient-Centered Medical Home

Privacy Practices



Upper Great Lakes Family Health Center (UGL) is a Federally Qualified Health Center and is a Federal Tort Claims Act (FTCA) Deemed Facility.
UGL receives funding from The U.S. Department of Health and Human Services and has Federal Public Health Service deemed status with respect to certain health or health-related claims, including medical malpractice claims for itself and its covered individuals.
This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H80CS26511 Health Center Cluster, total award amount of $1,839,050 with 89.9 % financed from nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.