Mobile & School-Based Care Form

Sharing Your Information Jordan Valley Health (JVH) uses a tool to electronically submit prescriptions on your behalf to the pharmacy of your choice. Limited information about you and the medication will be securely transmitted to support the prescription order. JVH will sometimes utilize your contact information including phone, text, email, and mail to send you appointment reminders, information about the clinic, health education, and information which may contain protected health information, or to ask for feedback. Please help us keep your contact information up to date including your phone number, home address, and email. Limited Verbal Release of Protected Health Information (PHI) Jordan Valley Health (JVH) gives you the option to name other persons who can contact JVH to talk to JVH about your (or your dependent’s) care, treatment, payment, or appointment schedules. These people cannot make decisions about your (or your dependent’s) care. JVH will ask these people to identify themselves before sharing PHI. PHI will not be shared with persons who are not authorized by you. I authorize limited release of my PHI as told above to the following person(s): "and the ‘full legal name, relationship, DOB, and phone."

Unless a child (i.e. minor) has a life-threatening injury or illness, doctors are required by law to have permission from the parent or legal guardian to treat anyone under the age of 18. This form is necessary when a child under the age of 18 needs care and is not with their parent or guardian. Jordan Valley will not provide care for children in the care of a relative or baby-sitter without a written consent from their parent or legal guardian.

Jordan Valley Health (JVH) is committed to providing patients the highest quality of care and pursuing excellence in our services and interactions. We share this information with you to help you understand and prepare for your care and responsibilities as a patient of JVH. JVH collects payment at time of service including copays, deductibles, and/or sliding and other fees that may be due. JVH accepts cash, checks, Visa, Mastercard or Discover card. Past due payments may be referred to a collection agency. JVH offers payment agreements if needed. JVH offers a pre-paid discount or a sliding fee discount. Full payment is due at the time of service. As applicable, JVH will confirm your current Medicaid or Medicare coverage at each visit. Please provide your current benefits card. If Medicaid or Medicare denies payment for your services, you are responsible for the balance due. I request that payment of authorized Medicare, Medicaid or other insurance company benefits be made either to me or on my behalf to JVH for any services provided to me by that party who accepts assignment. I understand the regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to release to the Social Security Administration and Centers for Medicare and Medicaid Services or its intermediaries or carriers any information needed for this, or related Medicare or other insurance company claim. I understand billing information relating to services I receive could be released to my insurance provider for payment of services received. I permit a copy of this authorization to be used in place of the original. I agree to pay Jordan Valley Health (JVH) for all billable services rendered to me and/or my ward. I acknowledge payment is due at the time of service and payable upon receipt of a monthly billing statement. If payment is not received within 90 days of the date of service, the balance may be referred to a collection agency. I understand I can enter into a payment agreement with the support of Jordan Valley Health's billing department if I am unable to pay the balance in full at the time of service. I understand that, after 6 months, any unused prepayments or copay amounts will be applied to any outstanding balances on my account before a refund is issued. I acknowledge that access to services at JVH will not be restricted due to my inability to pay amounts owed. However, I agree to work with Jordan Valley Health to establish an appropriate payment plan to address any outstanding balances.

It is important you keep to your appointments to stay healthy. If you cannot keep your appointment, please call us right away, but no less than 24 hours before your appointment. If you miss too many appointments, JVH may limit how you can schedule in the future. JVH assures certain rights to patients while asking patients to fulfill certain responsibilities. The Patient Rights and Responsibilities statement is publicly posted in our clinics. You can request a complete print copy of Patient Rights and Responsibilities at any time within our clinics. JVH may sometimes use or disclose limited protected health information (PHI) about your medical, dental, vision, or behavioral health care with other entities to coordinate your care, assure payment for services, or to support health care operations. Some examples of this disclosure include submission of electronic prescriptions on your behalf, billing and/or payment data shared with third-party service vendors and contact information for appointment reminders or feedback requests. Additionally, JVH may use or disclose your PHI without authorization when there is an emergency or when JVH is required by law to do so. Other uses or disclosures of your PHI can only be made with your written authorization. The Notice of Privacy Practices statement is publicly posted in our clinics. You can request a complete print copy of Notice of Privacy Practices at any time within our clinics. Review it to learn how protected health information about you may be used and disclosed and how you can get access to this information.