Patient Forms

Patient Registration Form
File Size: 520 kb
File Type: pdf
Download File
Health Questionnaire
File Size: 166 kb
File Type: pdf
Download File
Payment Policy and Patient Responsibility Form
File Size: 548 kb
File Type: pdf
Download File
Release of Information
File Size: 64 kb
File Type: pdf
Download File
Notice of Privacy Practices
File Size: 555 kb
File Type: pdf
Download File
Privacy Practices Acknowledgement Form
File Size: 141 kb
File Type: pdf
Download File
Medicare Annual Wellness Questionnaire
File Size: 341 kb
File Type: pdf
Download File

Screening and Immunization Resources

Immunization Recommendations: Birth - 6 years old

Immunization Recommendations: 7 - 18 years old 

Men: Stay Healthy at Any Age - Health Screening Guidelines

Women: Stay Healthy at Any Age - Health Screening Guidelines 

Choose My Plate - Tips for a Healthy and Balanced Diet

Insurances We Accept

Always verify coverage with your
​insurance company directly    
  • AARP Medicare
  • Aetna
  • ​Atrio
  • Beech Street
  • BlueCross BlueShield
  • BCBS MedAdvantage
  • Care Oregon
  • CareOregon Advantage
  • Caremark
  • Cigna
  • Conventry
  • ​Devoted
  • First Choice
  • First Health
  • GEHA​
  • Health Net ​
  • Healthshare  
  • ​Humana​​​
  • Kaiser Added Choice
  • Lifewise
  • ​Mail Handlers
  • Medicare
  • Motor Vehicle Ins
  • MHN Caremark
  • MODA/ODS
  • Optum Care Network
  • Oregon Medicaid
  • Pacific Source
  • Progressive
  • Regence​
  • Tricare / Triwest
  • ​Trilium
  • UMR
  • UnitedHealthcare
  • Wellcare

Resources for the Uninsured

Uninsured / Self - Pay Patient Rates 

$130 for New Patient Appointments

$100 for Established Patient Appointments

The above fees will cover evaluation of a single illness or injury.  If other services or a more comprehensive evaluation and treatment are required, there may be additional charges.   
Discounted Lab Work 
We offer lab work to uninsured patients at a discounted rate. If you are interested in more information, please contact the clinic at 
(503) 665-1010.  
Options for Making Payments 
You may pay by cash, check, or credit/debit card. 
 Payments can be made in person, by phone, by mail or online here.