Portage HealthPortage Health

Forms

Each of the following forms is a PDF. 

PDFIcon 

Acknowledgement of Receipt of the Notice of Privacy Practices of Portage Health

Complete this form to acknowledge that you receive and understand the Notice of Privacy Practices of Portage Health....  

PDFIcon 

Authorization for Use and/or Disclosure of Protected Health Information

Use this form to authorize Portage Health Medical Group to send your Protected Health Information to an individual or institution (such as another health care provider)... 

PDFIcon 

Authorization to Disclose Medical Information

Use this form to authorize Portage Health Medical Group to disclose medical information about your health care to specific individuals... 

PDFIcon 

Outpatient Authorization for Examination and Medical Treatment

Use this form to consent to examination and medical treatment by Portage Health Medical Group clinical staff for yourself or for a minor for whom you are a parent or legal guardian....