Telehealth Forms:
General Forms
Demographic/Intake Form
Sliding Fee Scale Application
​
Behavioral Health Forms (Currently Unavailable)
Informed Consent Telehealth Form
New Patient Adult 
New Patient Child 
PHQ-9

General Forms:

NDHSAA Preparticipation

​Physical Evaluation Form

Sliding Fee Scale Application 

Sliding Fee Scale Waiver

Demographic Form

Patient Responsibility Notice

Release of Information Form -for Medical & Dental
​
Psychiatric NP Patient Forms:
Adult Intake Form

Child Intake Form

​Release of Information Form-for Psychiatric NP

Informed Consent

Please Email completed forms to 
​BH@northlandchc.org

Becoming a Patient

As a patient of Northland Health Centers, we live by our motto “Our Family Caring For Your Family”. Each of us at Northland Health Centers is pleased to have the opportunity to provide you and your family with high quality healthcare. Whether you need a routine physical exam, prenatal care, immunizations, help managing your diabetes, depression, hypertension or urgent care, you can trust to us provide high quality healthcare. We are committed to your health and the health of the communities we serve! Before you are seen by one of our providers, we will need some basic information. We will need your current legal photo ID, your health insurance, Medicaid, and/or Medicare card, and for you to complete a medical history form.

We can even provide services to you if you do not have insurance! We encourage all patients, regardless of their insurance or financial status, to apply for discounted healthcare services. The application process is simple and takes no more than a few minutes to complete. Our Sliding Fee Application is used to determine if you and/or your family qualify based on your family size and income. Team members at any of our clinic sites can explain the details of applying for our sliding fee programs or you can contact our Eligibility Coordinator at 701-448-2054. You must provide proof of income when applying for discounted services.

Team members at any of our clinics are happy to help you make a medical appointment. You will be asked to provide your name, address, phone number, Date of Birth (DOB) and insurance information.

Please arrive 20 minutes prior to scheduled appointment time to complete required paperwork. Please bring your current legal photo ID and current insurance card.

*For appointments with our Psychiatric Nurse, all paperwork must be complete prior to the appointment. If you arrive 15 minutes or later or do not have the paperwork completed, your appointment will be rescheduled.