New Patient Forms

New Medical Patient Paperwork          English           Español​

 

These are the forms you will need as a medical patient if you have not been seen at LVHC within the past two years.  Please take your time to fill them out and bring them to your first visit.

 

For Individual Medical Forms Click Here

New Dental Patient Paperwork           English           Español​

 

These are the forms you will need if you have not been seen at the LVHC Dental clinic within the past two years.  Please take your time to fill them out and bring them to your first visit.

 

Patient Handbook

 

This contains detailed information about out Health Center's services, policies, prescriptions, and your Rights and Responsibilities as a patient.

Consents, Releases, and Disclosures

Consent to Treatment of a Minor

 

A parent or legal guardian may use this form to authorize another adult to provide the consent of 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.

Other Forms

Sliding Scale Discount Application           English        Español​

 

The sliding fee discount program includes a schedule of discounts for services that ensures financial barriers to care are minimized for patients who meet certain eligiblity criteria that are based on family size and income.

Family PACT Form

 

Family PACT is a state program that pays for many sexual and reproductive health services like pregnancy tests, birth control, STI testing and treatment, and counseling.  Family PACT services are confidential, and you can get them regardless of your age or immigration status.

Sports Physical Form                              English         Español​

 

These are the forms that you will need to fill out to receive a sports physical.  Please take your time and fill them out to the best of your ability and bring them to your scheduled sports physical appointment to save time in the waiting room.

Application for Disabled Person Parking Placard or Plates

 

You may qualify for a DP placard or DP license plates if you have impaired mobility due to having lost use of one or more lower extremities, or both hands, or have a diagnosed disease that substantially impairs or interferes with mobility, or one who is severly disabled to be unable to move without the aid of an assistive device.  you may also qualify if you have specific, documented visual problems, including lower-vision or partial-eyesightedness.

Claim for Disability Insurance Benefits

 

Disability Insurance was established in 1946 to provide short-term benefits to eligible California workers who suffer a loss of wages when they are unable to wowrk due to a non-work-related illness, injury, or pregnancy.  To learn more about DI, view the State Disability Insurance FAQs.

Applications

LVHC Employment Application

 

These are the forms that are needed to apply for an employment position withing the Long Valley Health Center.  Please take your time filling out these forms and submit them either online on our Job Opportunities page or in person to our Front Desk staff.

LVHC Governing Board Application Packet

 

In order to apply for membership on the Health Center Board, the completed application must be received in our Personnel Office.  Prospective Board members are expected to attend Board meetings prior to their election in order to acquaint themselves with their responsibilities, and as a demonstration of their intention to fulfill the obligations of our Board.  Thank you for your interest in joining the Board of Long Valley Health Center.

LVHC Scholarship Application

 

The Governing Board of Long Valley Health Center awards scholarships to encourage students who wish to pursue careers in the field of health care.  Scholarships are awarded based on academic achievement, citizenship, individual initiative, and career objectives.

Long Valley Health Center:

50 Branscomb Rd,

Laytonville, CA 95454,

phone: 707-984-6131

Long Valley Dental Clinic:

51 Branscomb Rd,

Laytonville, CA 95454,

phone: 707-984-8222

For Life-Threatening Emergencies, Call 911.

For After-Hours Medical advice only, call 888-214-3763

Legal Statement

Long Valley Health Center receives funding from the United States Department of Health and Human Services (HHS) and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. Any such claims must be filed in Federal Court. 

For our Patient Handbook, click here.

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