Patient Documents & Forms | Psychology & Comprehensive Health Clinic
New and current patients of Pacific Psychology & Comprehensive Health Clinics can find all their required documents and forms online.
For New Patients
It is important that our new patients have reviewed our new client orientation and informed consent as well as our notice of privacy practices. Please review the following documents before your first appointment. We can document your receipt of these documents via this signature page which can be received via mail or fax or we can document this verbally at the start of your first telehealth appointment.
Secure Email and Medical Records via MyChart
We strongly encourage all patients to sign up for MyChart to communicate with their clinicians about appointments, submit required documents, and receive medical records. We have written instructions in English and Spanish, as well as video instructions in English and Spanish.
If your child is 12 years or older, the parent or guardian must complete the MyChart parent-child proxy form to access their child's record via MyChart. If you are an adult who would like to authorize another adult to access your record via MyChart, please complete the MyChart adult proxy access form. This can be mailed or faxed to one of our clinics.
If you have requested we send your medical records via MyChart, instructions here on how to view and download them.
For Self-Pay Patients
For patients utilizing income based discounts to pay for services at PCH we are required to update your income documentation every 6 months. These documents can be received via mail or fax or for telehealth patients we can document receipt verbally via a phone conversation with a clinic staff member. These documents may include some or all of the following:
PCH Self-Pay Agreement: this document is to be completed every 6 months for self-pay patients.
Request for Restriction Not to Bill Health Plan: this document is to be completed every 6 months for all patients paying out of pocket for services to acknowledge that we are unable to bill their health insurance plan.
PCH Self Declaration of Income Form: this document is to be completed every 6 months for self-pay patients unable to provide income documentation. Submission of income documentation to clinic staff (tax summary, pay stubs, etc.) is the preferred method for income documentation.
Request Your Medical Records
To receive a copy of your medical records or request they be sent to another provider, download and complete this authorization and mail or fax to the clinic where you receive services.
Notice of Privacy Practices
The PCH is committed to safeguarding your protected health information and complying with all local, state, and federal laws and regulations. Our notice of privacy practices can be found here.
Pacific Psychology & Comprehensive Health Clinic | Portland
1411 SW Morrison St, Suite 310 Portland, OR 97205
503-352-2400 | Fax: 971-266-2955
Pacific Psychology & Comprehensive Health Clinic | Hillsboro
222 SE 8th Ave, Suite 212 Hillsboro, OR 97123
503-352-7333 | Fax: 971-266-2956