New Patient Packet

Please call our office at 503-255-3544 before filling out this form. We want to ensure we are contracted with your insurance provider and find out if you have or need to schedule an appointment for your child.

Step 1 of 12

Company

This field is for validation purposes and should be left unchanged.

Parent or Guardian Information

Parent/Guardian (Primary Contact) Legal Name

First Last

Relation to Patient

Birthday

MM slash DD slash YYYY

SSN

Live w/ Patient?

Yes

Preferred Phone #

Phone # Type

Cell

Home

Work

Second Phone #

Phone # Type

Cell

Home

Work

Other Phone #

Phone # Type

Cell

Home

Work

Parent or Guardian Information

Parent/Guardian (Secondary Contact) Legal Name

First Last

Relation to Patient

Birthday

MM slash DD slash YYYY

SSN

Live w/ Patient?

Yes

Preferred Phone #

Phone # Type

Cell

Home

Work

Second Phone #

Phone # Type

Cell

Home

Work

Other Phone #

Phone # Type

Cell

Home

Work

Parent or Guardian Information

Email (We only have capability to list one email per family)

Appointment reminders- we will attempt to contact you to remind you of upcoming appointments.

If you wish to receive an additional automated reminder, please choose ONLY ONE of the options below

Text

Phone Call

Email as written above

Text Number

Phone Call Number

Interpreter services are available

Please let us know if you need interpreter services

Yes

Primary Address for all children listed below

Street Address

Apt

City

State

Zip

Patient Information –list all children who are or will be seen at our clinic

Legal First Name

Legal Last Name

Birthdate

MM slash DD slash YYYY

Sex/Gender

Doctor

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Preferred Language

English

Other

Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Type "Other" language below

Patient Information –list all children who are or will be seen at our clinic

Legal First Name

Legal Last Name

Birthdate

MM slash DD slash YYYY

Sex/Gender

Doctor

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Preferred Language

English

Other

Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Type "Other" language below

Patient Information –list all children who are or will be seen at our clinic

Legal First Name

Legal Last Name

Birthdate

MM slash DD slash YYYY

Sex/Gender

Doctor

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Preferred Language

English

Other

Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Type "Other" language below

Do you have more than 3 children?

Yes

Patient Information –list all additional children who are or will be seen at our clinic

Legal First Name

Legal Last Name

Birthdate

MM slash DD slash YYYY

Sex/Gender

Doctor

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Preferred Language

English

Other

Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Type "Other" language below

Patient Information –list all additional children who are or will be seen at our clinic

Legal First Name

Legal Last Name

Birthdate

MM slash DD slash YYYY

Sex/Gender

Doctor

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Preferred Language

English

Other

Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Type "Other" language below

Patient Information –list all additional children who are or will be seen at our clinic

Legal First Name

Legal Last Name

Birthdate

MM slash DD slash YYYY

Sex/Gender

Doctor

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Preferred Language

English

Other

Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Type "Other" language below

Emergency Contact Information - Please list a friend or relative NOT living with you. For emergency use only.

Name

First Last

Relation

Phone #

Privacy Practices

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.

Signature(Required)

I accept the above policy.

Financial Policy

I acknowledge that I am aware of East Portland Pediatric Clinic’s financial policy, which I can review anytime by clicking here. A copy will also be provided upon request.

Signature(Required)

I accept the above policy.

Permission to Treat

I hereby authorize the physicians of East Portland Pediatric Clinic, P.C. to provide such medical services, regular or emergency, as may be determined to be in the best interest of those members of my immediate family, as listed above, who are minors. This authorization shall continue and be in full force and effect until revoked in writing by me.

Signature

Relationship to Patient

Date

MM slash DD slash YYYY

How did you hear about our clinic? Please check all that apply.

Friend

Family

Parent seen here as child

Web search

Hospital

OB-Gyn

Established Family

Other child already a patient

Insurance company

Notice of Referral Rights and Acknowledgement

THIS NOTICE DESCRIBES YOUR REFERRAL RIGHTS WHEN YOUR HEALTH CARE PROVIDER REFERS YOU TO ANOTHER PROVIDER OR FACILITY FOR ADDITIONAL TESTING OR HEALTH CARE SERVICES.

In accordance with Oregon law, when you are referred for care outside of our clinic, we {East Portland Pediatric Clinic, P.C.} are required to notify you that you may have the test or service done at a facility other than the one recommended by your physician or health care provider. Oregon law says (ORS 441.098):

A referral for a diagnostic test or health care treatment or service shall be based on the patient’s clinical needs and personal health choices.
The patient has a choice and when referred to a facility for a diagnostic test or health care treatment or service the patient may receive the diagnostic test or health care treatment or service at a facility other than the one recommended by the health practitioner;
If the patient chooses to have the diagnostic test, health care treatment or service at a facility different from the one recommended by a practitioner, the patient is responsible for determining the extent of coverage or the limitation on coverage for the diagnostic test, health care treatment or service at the facility chosen by the patient.
A health practitioner shall not deny, limit or withdraw a referral solely because the patient chooses to have the diagnostic test or health care treatment or service at a facility other than the one recommended by the health practitioner.

By signing below, I acknowledge that I have read and understand my referral rights as outlined above.

Patients over age of 18, Parent, Guardian, Responsible Party or Legal Representative signature

Date

MM slash DD slash YYYY

Signature for the following patient(s).

Name 1

DoB

MM slash DD slash YYYY

Name 2

DoB

MM slash DD slash YYYY

Name 3

DoB

MM slash DD slash YYYY

Name 4

DoB

MM slash DD slash YYYY

Name 5

DoB

MM slash DD slash YYYY

Description of Representative’s Authority

Parent/Legal Guardian/Patient Request to access Patient Portal

User Requesting Access

Please type: Parent/Legal Guardian OR if self, Patient First & Last Name

Notifications (including initial sign in link) can be sent to one of the below choices:

Text

Text Phone #

By signing below, I certify that I am the parent or legal guardian of the patient(s) listed below and I understand that my portal access (other than messaging and family account balance) will be revoked once the patient is 18 years old.

Signature of User Requesting Access:

Patient Name

First Last

DoB

MM slash DD slash YYYY

Relationship to user

Patient Name

First Last

DoB

MM slash DD slash YYYY

Relationship to user

Patient Name

First Last

DoB

MM slash DD slash YYYY

Relationship to user

Patient Name

First Last

DoB

MM slash DD slash YYYY

Relationship to user

Patient Name

First Last

DoB

MM slash DD slash YYYY

Relationship to user

Credit Card on File Authorization

I authorize East Portland Pediatric Clinic (EPPC), to charge co-payments not paid at time of service, and or unpaid 30 day balances due under $100 to the credit card listed below. For balances over $100, we will attempt to contact you to discuss payment terms. This authorization will remain in force on each of my children's accounts until they are no longer patients of EPPC or until a written request by the cardholder instructing EPPC to remove the authorization has been received. *For patients age 18 and older HIPAA restrictions apply.

Please give your card to the Front Desk to be scanned into our secure system.

Please choose one:

VISA

DIS

AMEX

Last 4 digits of card

Name on the card

Cardholder signature

Cardholder email for payment receipts

Date of authorization

MM slash DD slash YYYY

Patient Name

Patient's Date of Birth

MM slash DD slash YYYY

Patient Name

Patient's Date of Birth

MM slash DD slash YYYY

Patient Name

Patient's Date of Birth

MM slash DD slash YYYY

Patient Name

Patient's Date of Birth

MM slash DD slash YYYY

Patient Name

Patient's Date of Birth

MM slash DD slash YYYY

AUTHORIZATION TO RELEASE MEDICAL RECORDS

Release of Information to be sent to your previous primary care provider.

Patient Name

First Last

Date of Birth

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone #

Secondary Phone #

I authorize information released FROM: (please print)

Name

Street Address

City, State, Zip

Phone #

Fax #

Please SEND MY RECORD TO:

Where should we send your records? If you want your records sent to East Portland Pediatric Clinic, please type this information below:

East Portland Pediatric Clinic
10000 SE Main Suite 30
Portland, OR, 97216
Phone: 503-255-3544
Fax: 503-251-6827

If you want them sent to a different practice, please replace the information below with that practice's details.

Name(Required)

Street Address(Required)

City, State, Zip(Required)

Phone #(Required)

Fax #

Purpose of Release

Moving

Insurance change

Legal purposes

Exchange of information

Other

Personal use ($30 fee applies)

Dissatisfied with Clinic

If checked "Other", please list below

Type of Information To Be Released

Transfer of Care

Other

If checked "Other", please list below

By initialing the spaces below, I specifically authorize the release of the following medical records, if such records exist:

Mental Health/Treatment

Drug Abuse Diagnosis/Treatment

Alcoholism Diagnosis/Treatment

AIDS/HIV Test Results

Sexually Transmitted Diseases

The information to be used or disclosed pursuant to this authorization form may include information relating to: (1) acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection: (2) treatment for drug or alcohol abuse: or (3) mental or behavioral health or psychiatric care. This authorization may be revoked at any time by notifying E.P.P.C. in writing. Unless revoked earlier, this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request. I understand that any revocation will not have any effect on any information already used or disclosed before E.P.P.C. received the revocation. Records will be mailed within 30 days of receipt of completed authorization.

Signature of Patient or Person Authorized by Law

Today's Date

MM slash DD slash YYYY

Relationship to Patient