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.