Please download and fill out the following forms prior to your first appointment at Valley Oaks Health. This will help us get to know you and make your first visit as smooth as possible!
Form Language
It is the policy of Valley Oaks Health to ensure that no patient will be denied health care services due to an individual’s inability to pay for such services. To accomplish this goal, VOH has developed a Sliding Fee Program (SFP) in accordance with the guidelines and requirements of the Division of Mental Health and Addiction (DMHA) and Health Resources and Services Administration (HRSA). There is a discounted/sliding fee schedule available based on family size and income.
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Forms
Authorization To Consent
Child and Adolescent Physical Health Screening Form
Adult Physical Health Screening Form
Sliding Fee Program (SFP):
It is the policy of Valley Oaks Health to assure that no patient will be denied health care services due to an individual’s inability to pay for such services. To accomplish this goal, VOH has developed a Sliding Fee Program (SFP) in accordance with the guidelines and requirements of the Division of Mental Health and Addiction (DMHA) and Health Resources and Services Administration (HRSA). Click here to review the scale.
Privacy Practices
Valley Oaks Health’s Notice of Privacy Practices explains how your health information may be used and shared, the protections required under HIPAA and other federal privacy regulations, and your rights regarding your medical records. It also outlines how to request, correct, or restrict information, obtain records of disclosures, and file a complaint if you believe your privacy rights have been violated. Click here to review the Notice of Privacy Practices.
Formularios
Acuerdo de Admisión
Exámenes de Salud Física para Niños Y Adolescentes
Examen de Salud Física para Adultos
Sliding Fee Program (SFP):
La política de Valley Oaks Health consiste en garantizar que a ningún paciente se le nieguen los servicios de atención médica debido a su incapacidad para pagarlos. Para lograr este objetivo, VOH ha desarrollado un Sliding Fee Program (SFP) de acuerdo con las directrices y los requisitos del Division of Mental Health and Addiction (DMHA) y el Health Resources and Services Administration (HRSA). Haga clic aquí para revisar la escala.
Prácticas de privacidad
El Aviso de prácticas de privacidad de Valley Oaks Health explica cómo se puede utilizar y compartir su información médica, las protecciones exigidas por la HIPAA y otras normas federales de privacidad, así como sus derechos con respecto a sus expedientes médicos. También describe cómo solicitar, corregir o restringir información, obtener registros de las divulgaciones realizadas y presentar una queja si considera que se han violado sus derechos de privacidad. Haga clic aquí para revisar el Aviso de Prácticas de Privacidad.
English
