Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Privacy Confidentiality Form

  1. sign

  2. Privacy Confidentiality Form

  3. I have read and agree to comply with the terms of the Confidentiality statements and will read and comply with the Portage Manor Privacy Confidentiality of Protected Health Information (PHI) and Information Security Policies, as applicable, copies of which will be provided upon request.

    Portage Manor Licensed Residential Care Facility Programs & Affiliation:

  4. Check one box

  5. Check one box

  6. Leave This Blank:

  7. This field is not part of the form submission.