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Here you will find the new patient forms, as well as forms we ask current patients to update on a regular basis.
New patients: This is the packet (the 7 PDFs below) you receive as a new patient.
You can review so you know what information will be required, OR you can print/fill out the forms ahead of time (recommended).
Bring your completed forms to your 1st visit, or mail them to ACHC, PO Box 307, Fossil, Oregon 97830.
See below (scroll down) for the link to our Patient Forms in Spanish!
If you have any questions regarding the forms, please call 541-763-2725 for assistance. Thank you!
New Patient Registration (6 Pages) (pdf)
DownloadHealth Information Release (2 Pages) (pdf)
DownloadGender Orientation (1 Page) (pdf)
DownloadHIPAA Privacy (5 pages) (pdf)
DownloadMy Chart and Rx Refill (2 Pages) (pdf)
DownloadCredit and Payment Policy (1 Page) (pdf)
Download2024 Sliding Fee Application (5 pages) (pdf)
DownloadIf you have any questions regarding the forms, please call 541-763-2725 for assistance. Thank you!
1- SPANISH_New Pt Registration_7 pgs (pdf)
Download2- SPANISH_Release of Protected Health Info_2 pgs (pdf)
Download3- SPANISH_Orientation-Gender_1 pg (pdf)
Download4- SPANISH_2023 Sliding Fee Scale_4 pgs (pdf)
Download5- SPANISH_Privacy-HIPAA Info_5 pgs (pdf)
Download6- SPANISH_my chart & script refill_2 pgs (pdf)
Download7- SPANISH_Credit and Payment Policy_1 pg (pdf)
DownloadWe hope to provide you with the best experience of care that we possibly can. However, at times we may need to work together to resolve an issue. For that, we have a process called Patient Complaint Resolution. If you have an issue to resolve, please download, print, fill out and return this form to Asher Community Health Center, 712 Jay Street, PO Box 307, Fossil, OR 97830.
Patient Complaint Resolution form (pdf)
Download