The forms below are available for download
NEW PATIENT FORMS
New Medical Patient Paperwork
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.
INDIVIDUAL MEDICAL FORMS
New DENTAL Patient Paperwork
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.
INDIVIDUAL DENTAL 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.
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.
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
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.
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.