For Patients

Patient forms | Formularios del paciente

Below are some of the forms and information you will be given at your first Mosaic Medical appointment. If you would like to save time, print and fill out the registration form and bring it with you.

Estos son unos de los formularios que se pide completar en la primera visita. Si le gustaría ahorrarse tiempo, imprímalos y llénelos y tráigalos a su primera cita. Además, puede llenar la “Autorización para divulgar información de salud protegida” y enviarla por fax a nuestra oficina (al 541-383-1883) en cualquier momento para pedir copias de su expediente.

  • Additional Forms and Resources
    • Below are additional forms that you will also be asked to complete on your first visit. To save time, feel free to print these out and complete them as well. Make sure you bring them to your medical or dental appointment.
  • Authorization to Release Protected Health Information
    Autorización para divulgar información de salud protegida
  • Notice of Privacy Practices
    Aviso de prácticas de privacidad
  • National Health Service Corps Promise
    Promesa del Cuerpo nacional de servicios de salud
  • Health Records
    • If you would like to request copies of your Mosaic Medical medical or dental records, please complete the release of protected health information form (link above) and fax it to: 541-383-1883. You may fax dental or medical records to the same number.
    •  
    •  
Existing Patient Visit Checklist

In preparation for your visit at Mosaic Medical, please bring the following items with you:

  • Insurance Card (if you have one)
  • Identification

    Please bring if you are interested in applying for the sliding scale discount program. If you don’t work, work for cash or any other circumstance, you can discuss this with the patient navigator when you arrive.

  • All medications you began taking since your last visit

    Please bring the physical bottles with you so your provider can see the dosage information as well as medication name.

 

Applying For the sliding scale

If you are uninsured or underinsured, you may qualify for our sliding scale reduced fee program which is based on your household income. To determine your eligibility for discounted services or to enroll you with coverage with OHP, you will be asked to verify your household income. No one will be refused treatment because of an inability to pay.

Sliding Scale Application - English

Sliding Scale Application - Spanish

Proof of income (check stubs, tax return, Social Security checks, income from self-employment, alimony and/or child support, public assistance)

Please note that proof of income is not a requirement to be seen in our clinics, however in order to apply for OHP or the sliding scale, you must have your proof of income with you when you arrive for your appointment.