Download Forms & Other Important Information

Welcome to La Pine Community Health Center

Thank you for choosing us to be your health care provider. LCHC is a primary care health center where you will receive quality care.

Please review our patient forms for more information and to download forms you’ll bring with you to your appointments.

Download Forms

New Patient Packet (Adult)

Complete the attached packet for adult patient care.
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New Patient Packet (Pediatric)

Complete the attached packet for pediatric patient care.
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Discounted Fee Application

Complete the attached form to request discounted fees.
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Notice of Privacy Practices


Please review the attached Privacy Practices.
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Disclosure of Protected Health Information (Adult)
Complete the attached form for protection of your health information.
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Disclosure of Protected Health Information (Pediatric)
Complete the attached form for protection of your child's health information.
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Medical Release Form
Complete the attached form to request or send records to or from LCHC.
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MyChart Proxy Access Agreement - Adult
Complete the attached form to enable proxy access.
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MyChart Proxy Access Agreement - Teen
Complete the attached form to enable proxy access.
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MyChart Proxy Access Agreement - Child
Complete the attached form to enable proxy access.
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Need An Appointment?

We are here to serve you! Call (541) 536-3435 to make an appointment or ask any questions.

 

Walk-In Clinic

Need medical care for a minor illness or injury but can’t wait for an appointment? Visit our
Walk-In Clinic in La Pine.

Monday-Friday 8am–6pm After Hours Phone Number (541) 536-3435

 

Some examples of common walk-in conditions: sore throat, ear infection, minor cuts or burns, muscle strains and cold or flu symptoms.