FORMS

ACKR Clinic Release of Information Form

Use this form to return to us for requesting your most current medical records.
Please email it to info@theackr.com or fax it to: (541) 730-4147,
​drop it by the office, submit it to us through your Patient Fusion account, or use the ‘Upload File’ Button at the bottom of this page.

OMMP Minor Declaration Form

Please be sure to have this ‘OMMP Minor Declaration Form’ completed and notarized, for minors 17 and younger, PRIOR to the Minor’s appointment with our doctor.

OMMP Application

This is the blank OMMP Application Form, and it’s Instructions, that will need to be filled out and brought to your clinic appointment, unless you have a renewal application sent to you from the state.

OMMP Extension Request

Is your card is about to expire, and you haven’t filed an extension in the last 3 years, and aren’t able to get an appointment before your expiration date? This is the form you’ll want to submit to the OMMP, after scheduling your clinic appointment.

Naming a Facility as Caregiver

If you, or someone you know, would like to name their care facility as a Secondary OMMP Caregiver, be sure to complete this form and add it to your complete OMMP Application Packet. (There is no extra fee for this option.)

OMMP Change Request

Need to make a change to a current card? Don’t forget the $100 change fee when you submit this to the OMMP (Only $20 Veteran Change fee for Veterans or $20 Change Fee for Individuals with SSI.)

OMMP/OHA Verbal Release of Information

If you need to give someone permission to speak to the OMMP on your behalf, it is required to submit this form before they can speak to any one other than the Patient, regarding the patient’s application/card.

OMMP Replacement Card Request

Use this form for any requests for replacing a lost or stolen OMMP card. Remember, there is a $100 Replacement Card Fee when you submit this to the OMMP. (Only $20 Veteran fee for Veterans or $20 fee for Individuals with SSI.)

Submit a document to ACKR Clinic

Please use this form for submitting any necessary documents for your ACKR Clinic Doctor appointment. Be sure to click ‘Submit’.

  • Please upload documents here.

 

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