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Preventative Care Screening & Vaccinations provides insurance paid screenings at work-site clinics.

Register

Please call our support line at: 208-542-7111 if you need assistance while registering with Mountain View Hospital Preventative Services.

User Information

Personal / Contact Information

Demographic Information

Employment Information

Insurance Information

See back side of your insurance card

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Health Information

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N/A

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Personal Health / Social History

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Family Health History

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Terms & Conditions Please select the clinic you would like to attend.
Your actual appointment could vary by 15 minutes.
  Date Time Location

  1. MEDICAL CONSENT: I, the undersigned, consent to the services which may be performed during this visit or on an outpatient basis, including treatment, and which may include but are not limited to laboratory procedures, radiology procedures, diagnostic procedures, testing, medical, or pathology, emergency procedures, or hospital services rendered to me under the general and special instructions of a provider. If the patient takes any medications or other substances without orders from the provider, the patient hereby releases the hospital, clinic and physician from liability for any reactions that may occur. By signing this form, and on behalf of your heirs, executors, administrators and assigns, you agree to release Mountain View Hospital Preventative Services and/or the institution where this screening is conducted and their respective officers, directors, employees, agents, servants and subcontractors from any liability, claim or damage for any injury suffered as a result of undergoing the aforementioned testing, for any liability, or damage suffered as a result of inaccurate or erroneous outcomes, actions, or inactions taken as a result of this test.
  2. I authorize MVH to transfer myself to another health care facility should my provider determine it necessary. In addition, I also consent to the release of my medical records to such facility.
  3. RELEASE OF INFORMATION: I acknowledge that Mountain View Hospital (MVH) Preventative Services will use my information for the purpose of treatment, payment, and health care operations. I authorize MVH and any provider involved in my care to release medical information and supporting documentation of same as compiled in my medical records during the admission or outpatient visit to any organization which is or may be liable or responsible for payment of charges associated with my care and for all other purposes of benefit payment. I acknowledge that data from my patient records will be accessible to all health care providers participating in my care or treatment, including but not limited to physicians, nurses and technicians at the hospital, clinic, home health agencies, ambulance companies, and such other health care agencies involved in my care during and after transfer or discharge from the hospital/clinic. I further acknowledge that my medical records, photographs, negatives and or prints will be utilized in the hospital’s utilization review, performance improvement, peer review and other similar processes and studies. I also acknowledge that my medical records photographs, negatives and or prints may also be made available to governmental agencies as required by law. Information contained in my medical records may be extracted and complied for research purposes and the aggregated results (without individually identifying me) may be released to the public. I acknowledge that patient medical records at the hospital may be stored electronically and made available through computer networks to hospital personnel, physicians involved in my care and their offices. I acknowledge that my religious preference may be released to local religious organizations.
  4. FINANCIAL AGREEMENT AND ASSIGNMENT OF INSURANCE BENEFITS: In consideration of clinic care and services rendered, I hereby authorize payment directly to the above named hospital for hospital/clinic insurance benefits otherwise payable to me, but not to exceed the hospital’s regular charges. In addition, I authorize payment of Medicare/Medicaid/Insurance benefits to any contracted provider; this includes, but is not limited to laboratory procedures, radiology procedures, and anesthesia, pathology, or hospital/clinic services rendered to me under the general and special instructions of my provider during this encounter. In the event that my insurance policy was cancelled or inactive, I understand that I am financially responsible for charges. In the event that this account is not paid according to the terms of the hospital’s credit policy, I agree to pay interest at the rate of 18% APR and/or costs of collection, not to exceed reasonable legal fees and court costs.
  5. MOUNTAIN VIEW HOSPITAL IS A PHYSICIAN OWNED HOSPITAL: Upon request a list of ownership will be provided to you.
I herby certify and state that I have read, and that I fully and completely understand the Conditions of Admissions and Authorization for Medical Treatment, and that I have signed the Conditions of Admission and Authorization for Medical Treatment knowingly, freely, and voluntarily. Moreover, I certify and state that I have received no promises, assurances, or guarantees from anyone as to the results that may be obtained by any medical treatment or services.
 
If you have questions about registration or the terms of consent, please contact us at (208)542-7111.