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info@nwmedicalgroupwa.com

509-350-4785

509-350-4785

Northwest Medical Group

Employer Portal

Downloadable Patient & Employer Forms

Patient Information Forms

Patient Information Form- Every patient must have this form completed and signed for their visit. This form may be printed and completed in advance or a copy will be given at the time of appointment check in.

Release of Information Form- Please fill out the following form to request patient records.

Completed forms must be faxed back to: 509-380-9591

DOT Physical Forms (CDL)

DOT Packet- This form is what information DOT drivers can expect. This packet will be completed online at the clinic and does not need to be printed and completed beforehand.

Insulin-Treated Diabetes Mellitus Assessment Form- Commercial drivers with insulin-treated diabetes need to have this form completed by their treating clinician no more than 45 days prior to examination by a certified medical examiner. This form is required before a Medical Examiner's Certificate Form can be issued to a certified driver.

Employer Forms

Injury Information Form -This form gives us more information about your injury. If you’ve been injured, please complete this form in addition to the patient information form and bring it to your visit.

Authorization for Services Form -This form authorizes us to perform other types of services such as pre-employment physicals, drug screens, etc.
- This form will need to be returned back to us at least 1 day in advance for us to ensure we have the nescessary surpplies to provide services.
  - Please send the completed forms to: occmed@nwmedicalgroupwa.com

OSHA Respirator Questionnaire -This form authorizes us to perform OSHA Respirator Fit Testing & Renewal.
- This form will need to be returned back to us at least 1 day in advance for us to ensure we have the nescessary surpplies to provide services.
  - Please send the completed forms to: occmed@nwmedicalgroupwa.com

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