Patient Family Advisory Council Application - Aviva Health

(541) 672-9596 Umpqua Community Health Center is now Aviva Health!

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Nonprofit Summit
About
- About Us
- Our Mission
- Leadership
- Affiliations
- Awards
- News and Events
- Giving
- Get Involved
- Blog
Careers
Services
Patient Resources
Locations
Our Providers
Healthcare Education
- Family Medicine Residency

Aviva Health Patient and Family Advisory Council Application

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Applicant's Name: *

First

Last

Applicant's Date of Birth: *

Applicant's Phone *

Applicant's Email: *

Patient's Name (if different from above):

Patient's Date of Birth:

Patient's Provider Name: *

The Patient is Usually Seen at: *

Services Used (check all that apply):

Family Medicine
Dental
Behavioral Health
Pediatrics
Reproductive Health
Women's Health
Lactation Services
Pharmacy
Nutrition Services
Chronic Care Management
Vaccinations

What interests you about joining the PFAC? *

Do you have experience serving on a council or committee? If yes, please describe: *

What contributions do you feel you could provide to the PFAC? *

What topics or issues would you like the PFAC to address? *

What is your availability (ex: first Thursday of every month from noon to 1 p.m.)? *

I understand that Umpqua Community Health Center dba Aviva Health (Aviva Health) has a legal and ethical responsibility to maintain patient privacy, including obligations to protect the confidentiality of patient information and to safeguard the privacy of patient information, including but not limited to patient medical records and other individually identifiable health information (collectively referenced herein as "Patient Information"). In addition, I understand that during the course of my visit at Aviva Health, I may see or hear other confidential information such as financial data and/or operational information pertaining to the organization that Aviva Health is obligated to maintain as confidential (collectively referenced herein as "Confidential Information"). As a condition of my visit or affiliation with Aviva Health, I understand that I must sign and comply with this agreement. By signing this document, I understand and agree that (you must check every box): *

I will not disclose Patient Information and/or Confidential Information viewed on my visit without express permission from Aviva Health.
I will not proceed to any patient or "back of house areas" without being escorted by an authorized Aviva Health employee, unless I have obtained an entry badge and follow all building access procedures.
I will not access or view any information other than what is required to complete my duties. If I have any question about whether access to certain information is required for me to do my job, I will consult my guide or a Chief Compliance Officer.
I will not discuss any information pertaining to the organization in an area where unauthorized individuals may hear such information (for example, in hallways, on elevators, in the break room, on public transportation, at restaurants, and at social events). I understand that is not acceptable to discuss any Patient Information, Confidential Information or other information obtained through my assignment or affiliation with Aviva Health in public areas even if specifics such as a patient's name a re not used.
I will not make inquiries about any information for any individual or party who does not have proper authorization to access such information.
I will not make any unauthorized transmission, copies, disclosures, inquiries, modifications, or purging's of Patient Information or Confidential Information. Such unauthorized transmissions include, but are not limited to, removing and/or transferring Patient Information or Confidential Information from Aviva Health's computer system to unauthorized locations (for instance, home).
Upon termination of visit with Aviva Health, I will immediately return all property (e.g. keys, documents, etc.) to Aviva Health.
I agree that my obligation under this agreement regarding Patient Information will continue after visit, assignment, or affiliation with Aviva Health.
I understand that violation of this Agreement may result in possible civil or criminal prosecution, or loss of assignment or affiliation with Aviva Health.
I understand that any Confidential Information or Patient Information that I access or view at Aviva Health does not belong to me.
I have read the above Agreement and agree to comply with all its terms as a condition of continuing employment/assignment/affiliation.
I have received a signed copy of this document.

Name *

First

Last

Signature: *

Today's Date: *

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Nonprofit Summit
About
- About Us
- Our Mission
- Leadership
- Affiliations
- Awards
- News and Events
- Giving
- Get Involved
- Blog
Careers
Services
Patient Resources
Locations
Our Providers
Healthcare Education
- Family Medicine Residency

Contact

150 NE Kenneth Ford Drive
Roseburg, Oregon 97470
(mail or serve all legal documents to this address)

PHONE
541-672-9596

EMAIL
info@aviva.health

(For unsecured communications only. Please submit private medical information and questions through Patient Portal)

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