pediatric patient info forms

COPA Patient Forms

COPA Patient Forms

Expedite your child’s care by downloading these forms to complete before you arrive. If you have any questions, please feel free to call us. 

New Patients to COPA

Release Medical Records TO COPA from another Provider

Release Medical Records FROM COPA to another Provider

OSAA Sports Physical Forms and Medical Forms 

Behavioral Health Vanderbilt Form

My Health Online Portal Access

Payment Hardship Application

AUTHORIZATION FOR A CHILD’S MEDICAL TREATMENT | ‘CONSENT BY PROXY ‘ 
Consent by Proxy Authorization Form  
A parent or appointed guardian is required to accompany their child, 14 years or younger, to the child’s annual well-exam and for any vaccinations. The provider at those visits will inform the parent or guardian about the health of the child, discuss issues important to the patient, and in some cases COPA must receive permission from the parent or guardian to administer care.

SICK VISITS: A person who is authorized by the parent or guardian to provide consent for medical treatment may accompany the child for sick visit only, however, the following form must be completed and delivered to COPA for the visit or treatment to occur: Consent by Proxy Authorization Form  

APPLY FOR OREGON HEALTH PLAN
We are happy to assist you with your application for Oregon Health Plan. Please complete this document to finalize your enrollment. Oregon Health Authority Consent form for OHP Application.

FORMULARIOS EN ESPANOL

Intérpretes en todas las ubicaciones y teléfono

Bienvenidos a COPA, historial medico

Áutorizacion para liberar y/o recibir informacion medica protegida

Examen a la participatión en deportes en la escuela

Sistema de evaluación NICHQ Vanderbilt

Solicitud de Acceso Representante de MyHealth

Consentimiento de ayuda por parte de Socio Comunitario

Formulario de Solicitud de Dificultad

CONSENTIMIENTO DE PROXY PARA EL TRATAMIENTO MÉDICO | Se requiere que un padre o tutor designado acompañe a su hijo, de 14 años o menos, al examen de bienestar anual del niño y para cualquier vacuna. El proveedor informará al padre o tutor acerca de la salud del niño, discutirá temas importantes para el paciente y, en algunos casos, COPA debe recibir permiso para administrar la atención. Una persona autorizada por el padre o tutor para proporcionar el consentimiento para el tratamiento médico puede acompañar al niño para una visita por enfermedad solamente, sin embargo, el siguiente formulario debe completarse y entregarse a COPA para que se realice el tratamiento.  Autorizacion Por Consentimento Del Representante

PATIENT PRIVACY POLICIES

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Find Our Clinics
in Central Oregon

541-389-6313

CALL for Appointment, 24/7 Nurse Advice

Locations/Hours

FIND Our Clinics in Central Oregon

541-389-6313

Call for Appointment,
24/7 Nurse Advice

Locations/Hours

Find Our Clinics
in Central Oregon

541-389-6313

CALL for Appointment, 24/7 Nurse Advice

Locations/Hours

FIND Our Clinics in Central Oregon

Need help with the
Oregon Health Plan?

We Welcome All Children

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