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 the the PCH documents patients have been in receipt of 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 via MyChart with you Clinician

We strongly encourage all patients who are able 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.

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.

Contact Us

Pacific Psychology & Comprehensive Health Clinic | Portland
1411 SW Morrison St, Suite 310  Portland, OR 97205
503-352-2400 | Fax: 503-352-2403

Pacific Psychology & Comprehensive Health Clinic | Hillsboro
222 SE 8th Ave, Suite 212  Hillsboro, OR 97123
503-352-7333 | Fax: 503-352-7250