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1 Oregon Medical Association 11740 SW 68th Parkway, Suite 100 Portland, Oregon 972239028 (503) 6198000 PRACTICE ROUNDTABLE MEETING AGENDA TH May 9, 2013 8:30am10:30am Oregon Medical Education Foundation

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2. Print out the form on a standard white paper using a printer with good quality ink to ensure legibility.
3. Carefully read and understand the instructions provided on the form before proceeding to fill it out.
4. Begin by filling in your personal information, including your full name, date of birth, and contact details. Make sure to provide accurate information to avoid any potential issues.
5. If applicable, indicate your current medical condition or the reason for seeking medical assistance in the designated section of the form.
6. Follow the prompts on the form to provide a detailed medical history, including any previous illnesses, surgeries, or medications you are currently taking. Be as thorough as possible to provide a comprehensive overview of your medical background.
7. If required, provide information about your primary care physician or any specialists you are currently seeing.
8. Fill in the insurance details if applicable, including your insurance provider's name, policy number, and any other requested information.
9. Review the completed form for accuracy and completeness. Make any necessary corrections or additions before finalizing the document.
10. Sign and date the form in the appropriate sections, certifying that the provided information is true and accurate to the best of your knowledge.
11. Keep a copy of the filled-out form for your records before submitting it to the relevant authorities or healthcare providers.

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4. Individuals involved in legal or insurance matters related to their medical conditions may be asked to provide a completed Oregon medical form to support their case.
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