Compliance Forms

( ORS 127.800 - 127.897 )

•  Patient Request Form  - Revised 11/2012
•  Attending Physician Form  - Revised 11/2006

or  Attending Physician Short Form - Revised 11/2006
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.
 Consulting Physician Form  - Revised 11/2006

•  Psychiatrist/Psychologist Form - Revised 11/2006
•  Pharmacy Dispensing Record Form  - Revised 11/2006

Surveillance Forms

•  Attending Physician Follow-Up Form - 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 - Revised 10/2006
  Completed by OHA Staff. Data collected from death certificates and physician reporting forms.

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