| Home . Health Care Staff . Contact Us . Projects & Events . Visit Us . Library . Employment . Friends |
| 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. |
|
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 and Select "Save As" |
LVHC Employment Applications |
| 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". |