Patient Resources

Patient Forms

The relationship between you and your health care Practitioner is a very personal one and strictly confidential. When you request that we release information concerning your health care, we will ask you to sign a form specifically authorizing us to do so. You may be charged a fee for certain forms or for your medical records to be copied. Some forms your Practitioner will not be able to fill out without an appointment.

At your first visit to our clinic, you will receive a Notice of Privacy Practices, as required by HIPAA (Health Insurance Portability and Accountability Act). This notice outlines how our office uses your health information in coordinating and billing for your care.

Patient Forms

  1. Authorization to Release Medical Records
  2. Bone Density Screening Questionnaire
  3. Emergency Consent to Treat a Minor Patient
  4. Adult Medical History Form
  5. Newborn 0-7 Days Pediatric Developmental Screening
  6. 2 Weeks-1 Month Pediatric Developmental Screening
  7. 2 Month Pediatric Developmental Screening
  8. 4 Month Pediatric Developmental Screening
  9. 6 Month Pediatric Developmental Screening
  10. 9 Month Pediatric Developmental Screening
  11. 12 Month Pediatric Developmental Screening
  12. 15 Month Pediatric Developmental Screening
  13. 18 Month Pediatric Developmental Screening
  14. 2 Year Pediatric Developmental Screening
  15. 2 and Half Year Pediatric Developmental Screening

Important Information Regarding the Authorization to Release Medical Information

  • In accordance with Oregon law, please allow 30 days to fulfill your request.
  • Requests are processed in the order in which they are received.
  • Due to these time frames, we encourage you to submit your request well in advance of the date by which you will need your records.
  • For more detailed information, please see the instructions on the back of the Authorization to Release Medical Records form. This form is fillable online. Please type in the necessary information, print it, and fax it to 503.353.1293 or mail it to NWPC, 12300 SE Mallard Way, Milwaukie, OR 97222.

COPYING FEES

$25 for the first 10 pages. Each additional page is $0.25.