NEW PATIENT FORMS

New Medical Patient Forms (with HIPAA Acknowledgment)	These are the forms you will need as a new MEDICAL patient. Please take your time to fill them out and bring them to your first visit.

New Dental Patient Forms (with HIPAA Acknowledgment)	These are the forms you will need as a new DENTAL patient. Please take your time to fill them out and bring them to your first visit.

HIPAA Notice of Privacy Practices	Federal law requires that this notice is to be given to every new patient. Please take your time to read it over. You will be asked to sign a written acknowledgment at your first visit.

LVHC Patient Handbook	Contains detailed information about Health Center services, policies, prescriptions and your Rights and Responsibilities as a patient.

CONSENTS, RELEASES, & DISCLOSURES

Consent to Treatment of a Minor	A parent or legal guardian may use this form to authorize another adult to provide the consent to treatment of a minor.

Authorization of Use and Disclosure of Protected Health Information	Also known as a "Records Release" or "Records Request". This form may be used to Authorize the use and disclosure either From LVHC or To LVHC.

Authorization to Speak with LVHC Provider	This form may be used to give a Long Valley Health Center provider or employee permission to speak or exchange information with a specified individual or agency.

In accordance with
California Law and
Long Valley Health Center Policy,
all Requests for Release
of Medical Information
MUST be in writing.

California's Confidentiality of Medical Information Act (Civil Code 56.10) requires that: "No provider of health care . . . shall disclose medical information regarding a patient . . . without first obtaining an authorization."
In addition, Civil Code 56.11 states that for an authorization to be valid, it must be written, signed and dated by the patient (or legally authorized representative), and must state both the specific uses and limitations on the types of medical information to be disclosed, as well as uses and limitations on the use of the medical information by the persons or entities authorized to receive it.
Long Valley Health Center policy prohibits its employees from using verbal authorizations, by phone or in person, or from using a blanket authorization in any form.

OTHER FORMS

Sliding Scale Discount Application	You may be eligible to receive a discounted rate for your visit. Please take your time to fill the application out and bring it to your visit with proof of income.

HIPAA Acknowledgment of Receipt of Notice of Privacy Practices

Application For Disabled Person Parking Placard or Plates	State of California DMV: Form# REG195 (Rev. 8/2008)

Claim for Disability Insurance Benefits	State of California, Employment Development Dept: Form# DE2501 Rev.77 (3/06)

APPLICATIONS

LVHC Employment Applications

To Download, Right-click the link and
Select "Save As"

Adobe Acrobat
Format
( pdf )

WordPerfect
Format
( wpd )

MS Word
97-2003 Format
( doc )

LVHC Governing Board
Application Packet (pdf)

Adobe Acrobat format:
To Download, Right-click and Select "Save As".

LVHC Scholarship Application (pdf)

Adobe Acrobat format:
To Download, Right-click and Select "Save As".

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Last updated on March 23, 2012.