Patient Forms

General Patient Forms

1. Acknowledgment and Consent
2. Acknowledgment and Consent (Spanish)
3. Authorization to Release Medical Information *see note below
4. Authorization to Release Medical Information (Spanish) *see note below
5. Adult Medical History Form
6. Adult Medical History Form (Spanish)
7. Medicare Wellness Check-up
8. Depression Questionnaire (Adult PHQ-9)
9. Advanced Directive
10. Advanced Directive (Spanish)
11. Alcohol Screening Questionnaire (AUDIT)
12. Annual Wellness Visit Questionnaire
13. Bone Density Screening
14. Drug and Alcohol Screening Questionnaire (DAST)
15. Patient Reported Medications
16. Personal Health Information (PHI) Consent Form
17. Patient Health Information Consent (Spanish)
18. Sleep Assessment

Pediatric Forms

1. Pediatric Medical History Form
2. Pediatric Medical History Form (Spanish)
3. Emergency Consent to Treat a Minor Patient
4. Pediatric Recommendations by Age
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 Developmental Screening and M-CHAT
14. 24 months Developmental Screening and M-CHAT
15. 2 and Half Year Pediatric Developmental Screening
16. 3 Year Pediatric Developmental Screening
17. 4 Year Pediatric Developmental Screening
18. 5 Year Pediatric Developmental Screening
19. 6 Year Pediatric Developmental Screening
20. 7-8 Year Pediatric Developmental Screening
21. 9-10 Year Pediatric Developmental Screening
22. Pediatric Developmental Confidential Teen Questionnaire
23. 11-12 Pediatric Developmental Screening
24. 13-14 Pediatric Developmental Screening
25. 15-17 Pediatric Developmental Screening
26. 18-21 Pediatric Developmental Screening

*Authorization to Release Medical Information (ARMI)

The relationship between you and your Provider is a very personal one, and strictly confidential. 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.

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. There are some forms that your Provider will not be able to fill out without an appointment.

Regarding the ARMI, keep in mind:

• 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 Information ARMI 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 Suite 160, Milwaukie, OR 97222.

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

Download the ARMI now >