Marion and Polk counties
Primary care forms

Return to Marion Polk main page.

Please call our intake offices (971-202-5500) before you complete the primary care application form (below) so we can confirm that we can help you. Be sure to have your current insurance card and patient address information when you call.

  • Complete all information on this form. Missing information may delay the admission process.
  • Return form by mail, fax or email. If returning by email, please contact our office so you can encrypt your paperwork before sending as email transmissions may not be secure.
  • We will contact you if we have further questions or when we are able to offer you an appointment. Please keep seeing your current provider until we have completed an intake visit with you.

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Housecall Providers document links:

 

For the most up-to-date information about our current availability and service area, please contact our intake department at 971-202-5500.

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