Patient Information & Forms - Community Health Services of Lamoille Valley

Download Financial Assistance Form

Download Community Health Pharmacy
Prescription Form

Download our Patient Bill of Rights

Download our Demographic Information Form

Substance Use Treatment and Mental Health Information Release Form

Medical Record Release of Information Form

500.332D Statement of Disagreement of Denial to Release PHI Form

500.332E Request for Amendment Correction of PHI Form

500.332G Request for Accounting of Disclosure Request Form

500.332H Request For Specified Method of Communication Form

500.332I Request For Restricitions on Protected Health Information Form

500.332K Workers Compensation Request Form

500.332L Neurology Right To Access PHI Authorization Form

Community Health Services of Lamoille Valley (CHSLV) is funded in part through a grant from the U.S. Health and Human Services Administration and generous community support. CHSLV is a Health Center Program grantee under 42 U.S.C. 254b and a deemed Public Health Service employee under 42 U.S.C. 233

This health center receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.