patient forms

Epic Care Everywhere Opt Out Form
Proxy Access to Others' MyChart

All new patients and patients we haven’t seen within two years must fill out a medical history form. Click the link below to view and download the form. You can call our Health Information department at 541-322-2353 to give your medical history by phone, email to, or fax to 541-322-2381. 


This policy describes how medical information about you may be used and disclosed and how you can get access to this information.


Please download and complete our orthopedic patient intake forms before your visit to ensure a streamlined and personalized care experience. Bring the completed forms to your appointment. If you have any questions, our team is here to assist you.

If you are seeing a neurosurgeon or physical medicine and rehabilitation doctor, you can fill out your intake forms at check-in.


To receive a copy and/or inspect your medical and billing records, please fill out this Release of Information Form and mail, email, or fax it to the Health Information Department at The Center.

Mailing Address:
The Center
Attention: Health Information Dept.
2200 NE Neff Road, Suite 200
Bend, Oregon 97701

Phone: 541-322-2350
Fax: 541-322-2381

Office hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.


Your personal health information is absolutely secure – even more than a paper chart. Electronic records are protected by HIPAA compliant safety measures including system security, strict user permissions, and passwords. An electronic health record makes sharing information easier, but only with those who are authorized to receive the information. This provides continuity of care to patients and the system, and includes safety features that ensures only those participants in your care have access to your information. If you have questions please contact the Privacy Officer at 541-322-2329.


This federal law addresses the right of patients to have their medical information kept private and confidential. HIPAA applies to all clinics, providers, and staff affiliated with The Center. Under HIPAA, any electronic, written, or oral health information that can identify a specific patient is considered Protected Health Information (PHI). Your health care information is a personal matter and we are committed to protecting its confidentiality.


As a requirement of HIPAA, you will receive a complete copy of our Notice of Privacy Practices at your first appointment with the clinic. This document provides detailed information about your rights regarding your personal and health information and how that information may be used and disclosed by The Center.

Epic Care Everywhere Opt Out Form

The Center uses Epic electronic health record (EHR) system, including use of a secure electronic health information exchange (HIE); Epic Care Everywhere.  Care Everywhere allows health care organizations  that use Epic to instantly share your medical records via secure encrypted connections with other Epic organizations.  Care Everywhere allows treating providers, using Epic, real-time access to your medical history, including previous diagnosis, test results, medications, allergies, progress notes and other crucial information, without having to wait for these records to be transferred from one facility to another.

The ability to safely share health information with other members of your care team benefits you in many ways:

  1. Safer care: Updated and accurate allergy information and medication lists from you other doctors help make certain we prescribe the right medications.
  2. Coordinated care: Each member of your care team is aware of your plan of care.
  3. Efficient care: When your care team has access to test results and recent evaluations, you can avoid unnecessary duplication of tests and procedures, which saves time and money.
  4. Convenient care: You do not need to request that records be faxed or carry paper medical records.
  5. Engaged care: Sharing information and test results with your care team helps you actively participate in decision making regarding your health care.
  6. Emergency care: In case of an emergency room visit, the emergency department team will have access to your most current records, which allows for faster and accurate emergency care.


Through secure electronic health information exchange, we exchange health information only when providing care and services.  We share only information allowed by state and federal law and limit the exchange of sensitive health information.  We only exchange information we have confirmed as yours.  We match on your name, date of birth, sex, address, and phone number.  When you come to the Center, we can request available health information from your other care providers automatically and can also request manually, as needed.  Your other providers may require that we obtain your written authorization to do so.  When you go to other places of care, they may request information from The Center in a similar manner.

Please contact our Health Information Management (HIM) department if you have any questions or concerns about participating in this program.

Note:  To request to be exempted from the Care Everywhere health information exchange, please contact the HIM department at 541-322-2350 or download the Opt-out form and submit it to the HIM department.


The Center may need to communicate with your family or caregivers. By law, your authorization is required for us to do so.

Proxy Access to Others' MyChart

Sharing medical information can be a convenient way for parents and caregivers to assist their loved ones. If you do not already have a MyChart account, you will need to create one, even if you are not a patient at The Center.

Children 13 and younger: Parents with proxy access to minors have full access to MyChart including:

  • Clinical information including shared notes, test result, diagnoses, medications
  • Past and upcoming visits
  • Ability to send and receive messages to the clinical care team

Children 14-17: When the minor patient turns 14 years old, their parent’s proxy access automatically transitions from full access to limited access in accordance with Oregon state law.

  • The proxy no longer has access to any of the information above. This is to protect the minor from their parent seeing potentially sensitive information in MyChart.
  • Teens in this age range are eligible to create their own MyChart account.
  • There is a parent-teen expanded access class that can restore the proxy’s access to the above information by filling out the proxy form below.

Minor Patients Turning 18: When a minor patient turns 18 years old, proxy access is revoked.

Adults: To gain caregiver proxy access to another person’s medical information, the patient must fill out the proxy form.

To enroll a child or an adult you make health decisions for, please fill out this form and bring it to your next appointment, .

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