Patient Rights and Responsibilities
Foothill Community Health Center encourages patients and their families to report concerns related to care, treatment, services, and patient safety issues to any Foothill Community Health Center personnel or by calling The Joint Commission at 1-800-994-6610. Foothill Community Health Center so ensures that the following rights and responsibilities are preserved for all patients.
1. Smoking is NOT allowed on Foothill Community Health Center property.
2. You must bring the appropriate insurance card with you to each appointment.
3. A minimum payment is expected at the time of service.
4. Due to the small size of exam rooms and waiting room, please limit the number of people accompanying you for your appointment to no more than two. If it is necessary for you to bring small children, please bring another adult to supervise them. Please note pets are not allowed at any of the FCHC clinics (see insert on “No Pets” allowed policy)
5. Please bring a list of ALL medications with you at every appointment. This includes prescriptions, over-the-counter medications, and herbal medication.
6. Provide Foothill Community Health Center providers with full medical disclosure.
7. It is the patient’s responsibility to carry out the recommended treatment plan.
8. If your child is scheduled for a physical or immunizations a current immunization record MUST be brought with you.
9. Allow at least 30 days for completion of insurance forms, disability, transfer of treatment records, etc.
10. All refills on medications will be directed to your pharmacy after 5:00 pm the next business day.
11. All calls (i.e. appointments, cancellations, refills, medical/dental records, etc.) should be called to the following number (408) 729-9700. Weekends, holidays, and after-hours, all calls will be transferred automatically to our answering service. In case of emergency when the office is closed, please go to the emergency room.
12. Please give a 24 hour notice when canceling or rescheduling appointments. Cancellations can be made 24 hours per day, but must be made prior to your appointment time.
13. An established patient who arrives more than 15 minutes late for his/her appointment is considered to be a “No Show” for their appointment, regardless of whether or not the patient is seen that day.
14. An established patient who is a “No Show” for 3 appointments without canceling within a 12 month time frame will only be seen as a walk-in patient for emergencies only for that year. All new patients who no show their first appointment without notification to the clinic will also be allowed as walk-in only for that year.
15. An established patient is someone seen in one of our offices, by one of our providers.
16. If you have not been seen by one of our by one of our providers in 3 years you will be considered a new patient.
I, as a patient of Foothill Community Health Center, agree to the above patient rights and responsibilities.
1. Understand and make use of your rights.
2. If an interpreter is needed, the office will attempt to provide the assistance.
3. FCHC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
4. Privacy within the law.
5. Be assessed for pain.
Patients Rights and Responsibilities 07/24/2017
Patient Name (please print) Date
Signature of Patient or Guardian(is patient is a minor) Date
2670 South White Rd.
San Jose, CA 95148
F: (866) 931-7822
Our mission is to provide our community with high-quality comprehensive affordable medical, dental, and counseling services at our easily accessible health clinics. Seeing a need to balance the inequalities in healthcare, Foothill Community Health Center provides health services to everyone, regardless of their ethnicity, race, gender, sexual orientation, immigration status, or ability to pay for services.
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