Forms for Your Visit
Forms for Life House Community Clinic
Notice of Privacy Practices
Notice of privacy practices – Southcentral Foundation (SCF) respects your privacy and understands that your personal health information is a private and sensitive matter. We make a record of the care and services you receive and SCF, called protected health information (PHI). This information is needed to give you quality health care and comply with the law. For example, this information includes your symptoms, tests, diagnosis, treatment, health information from other health care providers, and billing and payment information related to those services. We will not disclose your information to others unless you authorize us to do so, or unless the law authorizes or requires us to do so.
Patient Registration worksheet
All new customers must complete both pages of the patient registration worksheet.
Sliding Discount Fee
The discount fee scale is a method for providing reduced fees based on a household’s size and income. To be eligible, the application must be completed every year or with any change in household income or size. If you have health care insurance, your insurance company will be billed. Customers who are Indian Health Service (IHS) beneficiaries may have their balance for services received covered by IHS.
Release of Information
The release of information forms give the Life House Clinic staff permission to request any prior medical forms from a provider or hospital where you were previously seen. These permissions can be revoked at any time by completing the revocation forms as well. If you are unsure if you have everything needed for these forms, use this checklist for guidance.
Forms for Chickaloon Village Traditional Council
Release of Information
The release of information forms give the Chickaloon Village Traditional Council staff permission to request any prior medical forms from a provider or hospital where you were previously seen. These permissions can be revoked at any time by completing the revocation forms as well. If you are unsure if you have everything needed for these forms, use this checklist for guidance.
Questions?
If you have a question about any of the forms, please feel free to give us a call at (907) 631-7665.
When you are finished with your forms, you or your provider can fax them to us at (907) 745-1855 or bring them to your appointment.