PATIENT FORMS

The forms below are available for download

NEW PATIENT FORMS

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.

Consent to Receive Text Messages

This form may be used to give a Long Valley Health Center provider or employee permission to perform some communications by text message.

OTHER FORMS

Sliding Scale Discount Application

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.

Sports Physical Form 

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.

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.

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.