Foster Patient Registration Form

Foster Parent Information

Name(Required)

First Last

Relation to Patient(Required)

Preferred Phone #

Phone # Type

Cell

Home

Work

Second Phone #

Phone # Type

Cell

Home

Work

Other Phone #

Phone # Type

Cell

Home

Work

Case Worker Information

Name

First Last

Phone

Caseworker Address or Branch

Street Address Address Line 2 City State ZIP Code

Foster Parent Preferred Email Address

Appointment Reminders –

We will attempt to call you to remind you of up coming appointments.

Please choose only one of the options below:

Text

Phone call

Email as written above

Interpreter services are available

Text Phone #

Phone call #

Primary Address for all children listed below:

Street Address

Apt

City

State

Zip Code

Emergency Contact Information

Please list a friend or relative NOT living with you. For emergency use only.

Name

Relationship to you

Phone #

Thank you for being a foster parent! By signing below you are stating that you have been authorized by DHS to seek medical care for the children listed on this page and are acknowledging that we have provided you with the following:

Please review your Opt In and Opt Out choices.

I acknowledge that the Physician’s Notice of Privacy Practices has been offered to me, and I can review it anytime by clicking here. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my or my child’s confidential information. I understand that the physician has reserved the right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided to me or made available to me.

Reviewed(Required)

Yes

Clinic Financial Policy/Understanding billing

Reviewed(Required)

Yes

Please feel free to pass these notices above on to the child’s case worker/guardian as needed

For continuity of care EPPC providers ask that you contact the child’s case worker and request that the following items below be made available to our clinic preferably before the first visit.

Transfer of care records - Most recent Well Child check, Last 2 years of Specialist Consults (if any), problem list, vaccine record, allergies, medication summary, lab/xray summary, visit list, vitals, and referrals
Consent or Refusal to vaccinate documentation from biological parents
Patient Oregon Health plan medical ID#, request- Managed care plan Providence (PHA), if not already done.
Documentation of Foster Care placement with you

Acknowledged

Yes

In order to keep accurate records, we request that Foster Parents inform us when the foster child is no longer in their care.

Signature

Foster Parent - Relation to Patient

Please call our office at 503-255-3544 before filling out this form. This form is for established foster families only.

Foster Parent Information

Case Worker Information

Appointment Reminders –

Foster Patient Information

Emergency Contact Information

In order to keep accurate records, we request that Foster Parents inform us when the foster child is no longer in their care.