PATIENT, USER GUIDES & FORMS

Notice of Privacy Policies
This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
Authorization Release
If you would like our team to coordinate care with another physician practice please complete the form below to authorize release of your medical record, or the authorization for another physician practice to disclose information to us.
*Note* If you do not have a way to fill out a digital signature you will need to print these forms out.
Financial Hardship Application 
This is an application for financial assistance at Northwest Medical Homes. We provide financial assistance in accordance with state and federal income requirements. You may qualify for free or reduced-price care based on your family size and income, even if you have health insurance. 
Right of Access for Family/Friend (HIPAA)
This form allows you to authorize a third party to have access to your PHI (protected health information) under the Health Insurance Portability and Accountability Act (HIPAA).
Discrimination is Against the Law

  • English

    Northwest Medical Homes complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Northwest Medical Homes does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.


    Northwest Medical Homes:

    Provides free aids and services to people with disabilities to communicate effectively with us, such as:

    • Qualified sign language interpreters

    • Written information in other formats (large print, audio, accessible electronic formats, other formats)


    Provides free language services to people whose primary language is not English, such as:

    • Qualified interpreters

     • Information written in other languages


    If you need these services, contact clinic manager.  If you believe that Northwest Medical Homes has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Sue Overley, 541-284-1706, susano@nwmedicalhomes.com. FAX: 541-747-0655. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Sue Overley is available to help you. 


    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services

    200 Independence Avenue, SW

    Room 509F, HHH Building

    Washington, D.C. 20201 

    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

  • Spanish

    Northwest Medical Homes cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Northwest Medical Homes no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo.


    Northwest Medical Homes:

    Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes:

    • Intérpretes de lenguaje de señas capacitados.

    • Información escrita en otros formatos (letra grande,      audio, formatos electrónicos accesibles, otros  formatos).


    Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:

    • Intérpretes capacitados.

    • Información escrita en otros idiomas.


    Si necesita recibir estos servicios, comuníquese con Claire Cieri. Si considera que Northwest Medical Homes no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona: Sue Overley, Compliance Officer 541-284-1706, susano@nwmedicalhomes.com. Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, Sue Overley está a su disposición para brindársela.

     

    También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación:

    U.S. Department of Health and Human Services

    200 Independence Avenue, SW

    Room 509F, HHH Building

    Washington, D.C. 20201 

    1-800-368-1019, 800-537-7697 (TDD)

    Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.