Patient Forms and Materials

Patient Registration Forms

• Notice of Privacy Practices
• HIPAA Acknowledgement and Consent
• Authorization to Verbally Disclose Protected Healthcare Information
• New Patient Form
• New Pediatric Patient Form
• Neurology New Patient
• Neurology New Patient Memory
• Neurology Headache Form #11008
• Neurology Migraine Assessment Questionnaire form #1117
• Neurology – Sleep Disorder Questionnaire Form
• Neurology 7-day Sleep Log form 10179
• Neurology Follow-Up
• Nutrition New Patient Consultation Form
• Nutrition Food Log (form-fillable PDF)
• Urology Consult – Patient History (form fillable PDF)

MyChart Forms

• MyChart Proxy Form – Adults
• MyChart Proxy Form – Minors

TELEMEDICInE INFORMATION

• MyChart Tip Sheet for Patient Video Visits
• Doximity Tip Sheet for Patient Video Visits

BILLING INFORMATION

• The Portland Clinic – Patient Financial Policies
• Lab Services Billing

PHYSICAL THERAPY APPOINTMENT FORMS

• Tigard Office
• South Office
• Core Wellness Program

Other Forms

• Blood Glucose Monitoring Log
• Eye Exam Fax Report
• Medical Record Amendment/Correction Request Form
• Release of Information Form (scroll down page for additional details)

OTHER MATERIALS AND INFORMATION

Patient Rights and Responsibilities

We want to encourage you, as a patient at The Portland Clinic, to speak openly with your healthcare team, take part in your treatment choices and promote your own health and safety by being well-informed and involved in your care. Because we want you to think of yourself as a partner in your care, you should know your rights and responsibilities. We invite you, your family or your personal advocate to join us as active members of your care team.

Download

Preventive Healthcare Guidelines

This resource is designed for the healthy patient without medical problems. These are our recommendations for routine exams, tests, counseling and vaccinations, designed to keep you at the best health possible. They are based on the U.S. Preventive Services Task Force recommendations, Centers for Disease Control and Prevention guidelines, and many other national and local resources.

Download

Release of Information / MEDICAL RECORDS

Release of Information (medical records from The Portland Clinic)

We have partnered with MediCopy to fulfill Release of Information requests. MediCopy is fully HIPAA compliant and adheres to all state and federal regulations concerning the release of medical information. 

To request your Portland Clinic medical records please visit MediCopy.net/Patients. Please provide an email address on the authorization to expedite the process and delivery method. Records sent via email, or to another provider, are complimentary. Requests are processed within two (2) business days after receipt by MediCopy.

If you have any questions, please contact MediCopy at 866-587-6274.

Health Information Management (medical records from other organizations)

To send your records to The Portland Clinic from another facility please contact the external facility to request medical records be sent to The Portland Clinic. You can use the following contact information below:

• Fax: 503-261-2600 (to fax records to The Portland Clinic)
• Email: [email protected] (to email records to The Portland Clinic)

Referring Patients to The Portland Clinic

If you are a provider and would like your patient to see one of our specialists, please complete the referral form* and fax it to our Patient Access Specialist: fax 503-214-4690, phone 503-802-6377. After we receive your referral, your patient will be contacted to schedule a specialist consult. If you are a patient seeking specialty care, please contact your Primary Care physician to refer you to The Portland Clinic. Many specialty physicians require diagnoses and chart notes before scheduling consultations.

Download

* A complete referral contains the following:

• Patient demographics
• Patient contact information
• Insurance information
• Referral information (if insurance requires referral: approval number and date span)
• Diagnoses
• Relevant chart notes

Advance Directive Form

As long as you can speak for yourself, you are always in charge of your health care. But what happens if accident, illness or disability robs you of the ability to make your wishes known? You can take action now to insure your wishes are followed when you can’t speak for yourself by filling out an Advance Directive for Health care. Ask your provider for a booklet that contains a legal form which allows you to express your wishes for care, if you become unable to decide in the future.

Download

NOTICE OF NON DISCRIMINATION

The Portland Clinic complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Download

21st CenTURY CURES ACT

The 21st Century Cures Act is intended to empower patients by providing faster and more complete access to their health data, whether that be via patient portals such as MyChart or by providing direct access to requesting and receiving complete medical record information. To learn more, click the link below.

Download

NEW MEDICAL CHAPERONE REQUIREMENT

A medical chaperone is available when your provider conducts a sensitive exam. As of July 1, 2023, the Oregon Medical Board (OMB) requires a medical chaperone be offered to all patients for these exams. A chaperone is trained to know what to expect during an exam and is there to ensure patient and provider safety. A chaperone is offered for your comfort, but you may choose to decline to have a chaperone present.

Please speak with your health care provider if you have questions about a sensitive exam or the use of a medical chaperone.

For more information, download the Oregon Medical Board’s patient education brochure “What to Expect During a Physical Exam” >>