Compliance Forms

( ORS 127.800 - 127.897 )

• Patient Request Form (7K) - Revised 04/2006
• Attending Physician Form (66K) - Revised 11/2006

or Attending Physician Short Form.  Please Note: All information required in the standard two-page Attending Physician Form must be included in accompanying copies of the patient's chart notes. (See Attending Physician Form.) Most physicians use the two-page form to avoid call-backs for missing data items. (50K) - Revised 11/2006

• Consulting Physician Form (66K) - Revised 11/2006
• Psychiatrist/Psychologist Form (17K) - Revised 11/2006
• Pharmacy Dispensing Record Form (18K) - Revised 11/2006

Surveillance Forms

• Reporting Physician Interview Form (19K) - Revised 04/2010
  Data collected from follow-up interviews with physicians. This document may be completed by the attending physician in lieu of a follow-up interview. NOTE: Older versions of this form will not longer be accepted by OHA after June 1, 2010.
• Chronology and Death Certificate Extract Form (8K)
  Completed by OHA Staff. Data collected from death certificates and physician reporting forms. - Revised 10/2006

The envelope used to return all forms should be marked as CONFIDENTIAL and mailed to:

Oregon Health Authority
Center for Health Statistics
PO Box 14050
Portland OR 97293-0050
Attn: Alicia Parkman

Hard copies of the rules and reporting forms can be obtained by emailing dwda.info@state.or.us or contacting us at:

Oregon Health Authority
Center for Health Statistics
PO Box 14050
Portland OR 97293-0050
Attn: Alicia Parkman
Phone (971) 673-1150