Patients Rights and Responsibilities 05/2017
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.


Understand and make use of your rights. 
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.


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 10 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 be terminated from the practice.  Refer to the No Show Policy for reinstatement guidelines.  All new patients who no show their first appointment will be terminated from the practice.
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 providers in three 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.

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Patient Name (please print)                                   Date

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Signature of Patient or Guardian (if patient is a minor)                         Date

2670 South White Rd.
Suite 200
San Jose, CA 95148
P: (408)729-9700
F: (866) 931-7822
Administration Office
Goal of Foothill Community Health Center

Foothill Community Health Center sites are Federal Tort Claims Act (FTCA) deemed facilities. Foothill Community Health Center is a 501 (c)3 non-profit community-based Federally Qualified Health Center (FQHC) offering comprehensive medical, dental, mental health, and specialty healthcare services. Foothill Community Health Center is a Health Center Program grantee under 42 U.S.C. 254b, and deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).
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