Patient Forms

Forms

Download Forms & Other Important Information

Simplify Your Visit

Streamline Your Healthcare Experience

Thank you for choosing us to be your health care provider. LCHC is a primary care health center where you will receive quality care. Please review our patient forms for more information and to download forms you’ll bring with you to your appointments

New Patient Packet (Adult)

Start adult patient care by completing this packet. Available for download or as an online form.

Download Form

Online Form

New Patient Packet (Pediatric)

Begin pediatric patient care by filling out this packet for children. Available for download or as an online form.

Download Form

Online Form

Discounted Fee Application

Apply for reduced fees by completing this form.

Download Form

Notice of Privacy Practices

Review the privacy practices document to understand how your information is used. Available for download only.

Download Form

Disclosure of Protected Health Information (Adult)

Authorize the sharing of your health information by completing this form. Download or fill out online.

Download Form

Online Form

Disclosure of Protected Health Information (Pediatric)

Enable the sharing of your child’s health information by completing this form. Download or fill out online.

Download Form

Online Form

Medical Release Forms

Request or send medical records to/from the LCHC by filling out this release form. Available for download only.

Download Form

MyChart Proxy Access Agreement - Adult

Authorize another person to access your health records on MyChart by completing this form. Download or fill out online.

Download Form

Online Form

MyChart Proxy Access Agreement - Teen

Allow a proxy to access a teen’s health information through MyChart by completing this form. Download or fill out online.

Download Form

Online Form

MyChart Proxy Access Agreement - Child

Enable access to a child’s health records on MyChart by completing this form. Download or fill out online.

Download Form

Online Form

ROI

Submit a Release of Information (ROI) request. Available as an online form only.

Online Form

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Contact Us

Contact information for each location and after-hours assistance.

Call Toll-Free

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24 hour on-call accessibility.

888-558-9674

After hours number

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Need medical advice from a care provider when we are closed? Call us to access the on-call provider.

541-536-3435

MyChart

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The MyChart portal provides 24/7 access to manage your healthcare needs efficiently and securely