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* 1. Our records show that you got care from a provider at OIH in the last 12 months. Please write your Oregon Integrated Health Primary Care Provider name below.

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* 2. Is this the provider you usually see if you need a check-up, want advice about a health problems, or get sick or hurt?

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* 3. How long have you been going to this provider?

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* 4. In the last 12 months, how many times did you visit this provider to get care for yourself?

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* 5. In the last 12 months, did you phone this provider’s office to get an appointment for an illness, injury, or condition that needed care right away?

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