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Patient Resources

Forms

Release of Information Authorization Form

Medical Dental

Medical History Form

Pediatric Adult Male Adult Female

Other Forms

Patient Comment Form  Sliding Fee Application

Medical Telehealth Consent Form 03272020

Bring to Your Visit

  • Photo I.D.
  • Insurance Card
  • Containers of current medications, vitamins & supplements
  • Sliding fee scale applicants – proof of income
  • Release of Information (ROI) form
Download ROI Form

What's New

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Sliding Fee Discount Application for 2024

Sliding Fee Program WE ARE COMMITTED TO QUALITY CARE REGARDLESS OF ABILITY TO PAY. If you do not have medical or dental insurance or if your insurance does not cover certain services, you may be eligible to enroll in our Sliding Fee Program. Fees are discounted based on household size … Read More +

All Updates

This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

Land Acknowledgment Statement

We acknowledge that our clinics are located on traditional, ancestral, and contemporary lands of Indigenous people who cared for and called these lands home for generations. Our clinics reside on Ojibwe and Dakota lands, and we recognize that the spirit of the Ojibwe and Dakota permeates these lands. The land we reside on has great spiritual and historical significance for Indigenous peoples past and present. We strive to build tribal relations and support tribal sovereignty in our community.

Lake Superior Community Health Clinic complies with applicable federal civil rights laws, and does not discriminate on the basis of race, color, national origin, age, disabilities, sex, sexual orientation, or gender identity.