Patient Forms

 

Please Address Forms to:

1234 Comercial ST SE
Salem, OR 97302

 
Open/Close Available Formsand InformationBlood Glucose Logs
If your provider has requested that you keep a log of your blood sugars, this is where you can find some that you might like to use. There are two of these available, one for those using insulin and one for those using oral medications only. Please print off and complete the one that is appropriate for you and bring it in at your diabetes follow-up visits.
Open/Close Available Formsand InformationBlood Pressure Log
View/Print/Download: » Blood Pressure Log
If your provider has requested you to monitor home blood pressures and bring in readings, this is a convenient form that you can print off to keep this record.
Open/Close Available Formsand InformationHealth Information Privacy Practices
This is a notice we are required to give every patient of our policies and ongoing efforts to keep your health information private. Please take time to review it and print it off if you wish. After you have a chance to review it, we will need you to sign The Health information and Privacy Practices Acknowledgement (HIPPA) form. This should be printed off and completed and turned in either by mail or in person at or prior to your first new patient visit.
Open/Close Available Formsand InformationMedical Records Release Authorization
View/Print/Download: » Medical Records Release Form
These forms must be completed both for transferring prior records from other providers to Physician’s Building Group and for transferring records from providers in Physician’s Building Groups to outside providers. This should be printed off and completed and turned in either by mail or in person. There are sometimes charges for transferring medical records and you should be contacted after you turn in the form if this is the case.
Open/Close Available Formsand InformationMotor Vehicle Accident Form
View/Print/Download: » MVA Form
Generally, motor vehicle accidents are covered under different insurances than your regular medical insurance, so a separate appointment and form must be completed for these visits. This should be printed off and completed and turned in either by mail or in person at or prior to your visit.
Open/Close Available Formsand InformationNew Patient Medical History Forms
Please print out the appropriate Medical History Form. There are two forms so choose the appropriate one. One is if you have a new primary care provider and the other is for your new diabetes and endocrine specialist. Fill out the form to the best of your ability and mail it or bring it in at or prior to your first new patient.
Open/Close Available Formsand InformationNew Patient Registration Form
If you are looking to become new patient here at Physician’s Building Group, please print off, complete, and turned in either by mail or in person. You will be contacted within one week after the form is received to set up a new patient visit if you have been accepted by one of our providers here at the clinic. If you have already been accepted as a patient here, please print and fill out the "New Patient Registration Form" and bring it with you to your first visit.
Open/Close Available Formsand InformationPhysician’s Building Group Patient Policies
View/Print/Download: » PBG Patient Policies
This is a general summary of some of our policies that may be of interest to our patient’s here at Physician’s Building Group. It can be reviewed or printed off as you wish.
Open/Close Available Formsand InformationRequests for Completion of Forms and Letters
Please print off and complete this form and turn it in either by mail or in person along with the form you wish to be completed. Your provider will then review the form. Depending on your provider and the form itself, an office visit may be required. If an office visit is not required, there is frequently a minimum charge of at least $10 to complete these forms or letters. We will always notify you prior to completing it if there is a charge or office visit involved. Payment must be made at the time the form or letter is picked up. Up to 5 business days may be necessary to complete your requests.