Download: Patient Forms & Information

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!

1- New patient registration_6 pages_(Forms) (pdf)

2- Release of protected health information_2 pages_(Form) (pdf)

3- Orientation-Gender_1 page_(Form) (pdf)

4- SFDP 2022 Application_5 pgs (pdf)

5- Privacy-HIPPA info_5 pages (pdf)

6- my chart & script refill_2 pgs (pdf)

7- Credit and Payment Policy_1 page (pdf)

Download: Patient Forms in Spanish

If you have any questions regarding the forms, please call 541-763-2725 for assistance. Thank you!

(NOTE: Form # 3 will be posted soon.)

1- SPANISH_New Pt Registration_7 pgs (pdf)

2- SPANISH_Release of Protected Health Info_2 pgs (pdf)

3- SPANISH_Orientation-Gender_1 pg (pdf)

4- SPANISH_Sliding Fee Scale_4 pgs (pdf)

5- SPANISH_Privacy-HIPAA Info_5 pgs (pdf)

6- SPANISH_my chart & script refill_2 pgs (pdf)

7- SPANISH_Credit and Payment Policy_1 pg (pdf)