Patient Forms

Registration forms

Adult Registration (for new patients, older than 18 years)

Pediatric Registration (for new patients, ages birth through 18 years)

Release of Information (ROI) forms

Authorization to Release Protected Health Information

New Patient Release of Information

Communications Permissions Form – Adult

Communications Permissions Form – Minor

Sliding Scale Discount Program form

Before filling out this application, learn about the Sliding Scale discount program. Read more

Sliding Scale Application

Grievance form

Patients and others may submit a complaint with Mosaic verbally by calling the main Mosaic Phone number at 541-383-3005, in writing by completing the grievance form and returning it to any Mosaic site, or by mail.

Grievance form

Other forms and PDF resources

Media Release form

Notice of Privacy Practices PDF