Patient Forms

Complete this form to be registered as a Unity Care NW patient.

Find out about your rights and responsibilities as a Unity Care NW patient.

Find out how your medical information may be used and disclosed. Unity Care NW respects your privacy, and we understand that your personal health information is very sensitive. We will not disclose your information without your approval or unless the law authorizes or requires us to do so.

If you are a caretaker (other than a parent, guardian, or relative) of a minor patient, complete this form to authorize care.

Complete this form to authorize care for a minor patient if you are a relative or have a kinship responsibility.

This for authorizes Unity Care NW to care for patients ages 13 and older without a parent or guardian.

Learn about insurance and billing practices at Unity Care NW.

To apply for the Sliding Fee Discount Program, complete the Application and provide proof of income.

Tell us if we can leave detailed phone messages and who we can speak to about your healthcare.

Tell us who we may release your records to or who may release your records to us.

Complete this form to provide your child's medical health history before receiving dental care.

Complete this form to provide your medical health history before receiving dental care.

This form provides your consent to receive dental services.

Patient demographic information helps us provide care and meet federal grant reporting requirements.

Patient demographic information about your child helps us provide care and meet federal grant reporting requirements.

To request transfer of your medical record to another facility or to request a personal copy of your medical record, complete a Release of Information Form.

Patients can use this form to request an amendment to their medical records.

This form authorizes consent to be examined and treated, as well providing a brief summary of your rights and responsibilities as a patient.

Adults can use this form to provide us with information about their health history.

This form is for the health history of patients under age 18.