Phone: 541-763-2725 ~ Fax: 541-763-2850
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.
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)
Download2- Release of protected health information_2 pages_(Form) (pdf)
Download3- Orientation-Gender_1 page_(Form) (pdf)
Download4- Sliding Fee Scale 2020_4 pages_(Form) (pdf)
Download5- Privacy-HIPPA info_5 pages (pdf)
Download6- my chart & script refill_2 pgs (pdf)
Download7- Credit and Payment Policy_1 page (pdf)
DownloadPatient Complaint Resolution Form
We 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)
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