Monterey Health Center Patient Information
New & Returning Patient Forms
Welcome to our clinic. Your medical care is important to us. Please arrive to your appointment 15 minutes early with the below forms filled out completely. Please bring your insurance card(s), drivers license, and your copay or coinsurance.
We are participating with most insurance plans. Insurance coverage changes, so please check with your insurance company to verify what services and providers are covered under your insurance plan.
Read our Credit & Payment Policies
If a co-pay is required through your insurance plan, we require payment at the time of service. We accept cash, personal checks, Visa, Mastercard, or Discover. If you do not have insurance you will need to pay at the time service is rendered. As a courtesy we provide a 25% discount to self pay clients for services if payment is made in full the day of your appointment. A $100.00 retainer fee will be required before seeing the doctor and will be applied towards any remaining balance if you will not be paying the full balance of your visit the same day of service.
What is an Advanced Directive?
An Advance Directive are instructions given by individuals specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to illness or incapacity. It also appoints a person to make such decisions on their behalf. The link below will connect you to a page where you can print off an Advance Directive packet. If you need assistance filling it out, please schedule an appointment with your provider. We request that you leave a copy with the clinic after you are finished to keep in your chart.
Physician Orders for Life Sustaining Treatment (POLST)
What is Polst?
POLST is a medical order for people with serious illness or frailty. If you are someone with a serious illness you can complete a POLST Form with your health care professional to direct the kinds of treatment you want in a medical crisis. POLST orders give you more control over the treatments you do or do not want to receive in an emergency situation. The form works to guide treatment decisions if you later lose the ability to speak for yourself.
If you have any questions or would like to fill out a POLST, please schedule an appointment with your provider.
More information is located at the Oregon POLST website.
Health History Male
Health History Female
Health History Child & Adolescent
Health Information Authorization
Authorization to release information to Monterey Health Center
Authorization for MHC to release information to another clinic
Electronic Prescription Consent Form
Financial Arrangements & Assignment of Benefits
Prescription refills are most efficiently communicated between the pharmacy and our office so that if there are any questions they can be quickly clarified between the pharmacy and physician.
Electronic Prescription Consent Form - we need this form on file to be able to fill or refill a prescription.
Please contact your pharmacy directly if and when you require a new prescription or you have a prescription refill request
All prescription refill requests require a 72 hour notification.
Our providers do their best at trying to keep on time with their schedule. However, there may be occasions or unforeseen circumstances where this is not possible. Therefore our staff will do their best to inform you if a provider is running behind schedule. Because our providers try to remain on time, if you are more than 15 minutes tardy for an appointment, you will be asked to reschedule. If you find it necessary to cancel or reschedule your appointment, a 24-hour notice is required. A fee may be incurred for no-show appointments and cancellations with less than 24 hour notice.