Patient Forms

New Patient Packets

We welcome patients of all ages– kids, teens, adults and seniors.

You can download the New Patient Packet, print it, and mail it in or drop it by one of our clinics in person.

You can also call and request that a New Patient Packet be mailed to you. Just fill it out and mail it back.

Our staff can help you complete the New Patient Packet and discuss payment
or insurance billing options. Please ask for one of our Outreach and Enrollment Specialists.

New Patient Packet Download:

New Patient Packet

Spanish Language Adult Patient Information

Your privacy is important to us. Plan to deliver your patient packets in person or by mail. Health center staff will not communicate or respond to healthcare related messages by email.

Other Patient Forms

In order to provide quality care and ensure security of patient information we require these additional forms and documents.

Notice of Privacy Practices

Notice of Privacy Practices Acknowledgment Form

HIPAA Authorization Form

Health Information Exchange Opt Out Form

Release of Information Request Form – Releasing Your Records from CCHC to Another Facility

Release of Information Request Form – Releasing Your Records from Another Facility to CCHC

Patient Grievance Form – This form has been made fillable for your convenience, please note it will need to be printed, signed, and dropped off or mailed to your clinic.

Sports Physical Registration Form

Sports Physical Registration Form – Spanish

New Patient Packets

Other Patient Forms

Serving Oregon's South Coast

The Mission of Coast Community Health Center is to increase the availability of affordable, high-quality healthcare for all.

Stay In Touch

Bandon Clinic

Port Orford Clinic

Outreach and Enrollment – Brookings