Patient Forms

New Patients

Registration Form

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

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Patient Rights and Responsibilities

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

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Notice of Privacy Practices

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.

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Children Under Age 18

Alternate Caretaker Authorization for Minor Patient

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

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Kinship Care Authorization for Minor Patient

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

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Unaccompanied Minor Authorization

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

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Insurance and Sliding Fee Discount Program

Insurance Benefit and Payment Obligation Form

Learn about insurance and billing practices at Unity Care NW.

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Sliding Fee Discount Program Application

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

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Receiving Care

Dental Health History - Children

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

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Dental Health History - Adults

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

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Consent to Dental Treatment

This form provides your consent to receive dental services.

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Demographics Form - Adults

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

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Demographics Form - Children

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

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Release of Information

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.

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Acknowledgements and Consent

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

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Health History - Adults

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

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Health History - Children

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

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