All Forms and Requests
All forms are in a digital and secure format. Available in both Spanish and English.
Simply click on the form link below, fill it out on your device, and click the submit button! Our main fax line is 541-639-4142.
For Washington clinic (formerly NorthShore) forms please click here. Please note these forms are not currently digital.
Authorized Caregivers for Minors - Fill out this form when you want other adults beyond a legal guardian or parent to be able to communicate with providers about a minor’s health care.
Authorization to Disclose Protected Health Information - This form is used to authorize the release or request of patient information.
Consent to Disclose Health Information Verbally - Filling out this form will allow us to talk about your medical care to those you have designated. This includes appointment and scheduling information, lab and test results, treatment information, and billing information.
Contact - Can't Find What You Need? Click the link to find contact information for One Community Health Clinics and Mobile Services.
Dental Sealant Permission Form - One Community Health will be onsite during the school year to provide FREE dental services. Please submit this form to take advantage of these FREE services.
La Clínica Mobile Medical Unit Appointment Request - Fill out this form to submit preferences for an appointment with our Mobile Medical Unit. We will give you a call back to schedule within 2-3 days!
Media Release - Authorization and Release of Information for Media/Public Relations, Fundraising, and Marketing.
Medicaid Enrollment Appointment - We have certified enrollment assisters, specializing in Oregon and Washington Medicaid plans. Click the link to schedule an appointment directly with us at both of our clinics.
Medical Records Request - Fill out this form to order a copy of your detailed medical records. You can specify the date range, which medical records, and the party receiving the copy of your medical records.
MyChart Adult Proxy Access - Fill out this form to share access to your MyChart account with another adult, such as a parent, adult child, or spouse.
MyChart Minor Authorization - Fill out this form (by parent or legal guardian) to allow parental access to your child's MyChart electronic record.
New Patient Registration - Fill out this form to send us your registration information and save time in the clinic.
Patient Complaint - Submit a complaint or grievance.
Request Appointment - Fill out this form to submit your day/time preferences for an appointment. We will give you a call back to schedule within 2-3 days!
Request for Correction-Amendment of Protected Health Information - Fill out this form to request a change to your health information; or those you have proxy.
SBHC Behavioral Health - Click the link to schedule a Virtual Behavioral Health Visit at our School-Based Health Center.
SBHC Registration - Fill out this form to send us your registration information and save time at the School-Based Health Center.
Schedule Covid Test or Vaccine - Click the link for information and scheduling of Covid tests and vaccines.
Sliding Scale Application - One Community Health offers a Sliding Scale discount based on your household income. Fill out this form to apply.
Volunteer and Donate - As a 501(c)3 nonprofit organization, One Community Health is always grateful to accept financial donations. Click the link to learn more.
Washington (NorthShore) Clinic Forms
Authorization to Communicate and Share Health Information - English/Spanish
Advanced Consent to Treat Minors - English/Spanish
Sports Physical Form - Washington - English Spanish
Sports Physical Form - Oregon - English Spanish
Adult Health History for new patients - English Spanish
Federal Poverty Level (FPL) Questionnaire - English/Spanish
Medicare Annual Wellness Visit Questionnaire - English Spanish