Patient Forms

Adult Proxy Access to an Adult’s MyChart Record

This form is for Adult’s that require access to another Adult’s MyChart records.

Application for Sliding Scale Discount Program

Sliding Scale Discount form will require details about the patient who is applying including Proof of Address from household members over 18 years old.

Authorization to Disclose Protected Health Information

This form is used to authorize the release or request of patient information.

Authorized Caregiver(s) 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.

Clases Perinatales

Perinatal Class Form available for Spanish speakers only.

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 Us

Can’t Find What You Need? Click the link to find contact information for One Community Health clinics and mobile services.

Free Dental School Services

One Community Health will be onsite at Hood River Valley schools during the school year to provide FREE dental services. Please submit this form to take advantage of these FREE services.

Good Faith Estimate Questionnaire

Use the form to view Good Faith Estimates for your medical services or items

Mobile Medical Clinic Appointment Request

Fill out this form to submit preferences for an appointment with our Mobile Medical Clinic. We will give you a call back to schedule within 2-3 days!

Parental/Guardian Proxy Access to MyChart for Child

Fill out this form (by parent or legal guardian) to allow parental access to your child’s MyChart electronic record.

Patient Complaint

Submit a complaint.

Prospective Board Member Application Form

If you are interested in being part of the OCH board, please fill out the form provided.

Request for Correction-Amendment of Protected Health Information – English

Fill out this form to request a change to your health information; or those you have proxy.

School-Based Services Appointment Request and Registration

Fill out this form to send us your registration information and save time at the School-Based Health Center.

School-Based Virtual Behavioral Health Services Request

Click the link to schedule a Virtual Behavioral Health Visit for students at South Wasco County schools.

Sliding Scale Discount Attestation

If proof of income is not provided or additional information needs to be provided, please fill out the following Sliding Scale Discount Attestation Applicant Form.

South Wasco County School District Appointment Request Form