General Documents

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General Documents

Overview

IFEHC reserves the right to request 100% Refundable Deposit

Interested in expediting service? This section shows the documents with which you need to be familiar. You will need these whether you are planning to visit Idaho Falls Employment Health Clinic's Free Health Clinic-Internal Medicine Clinic or Employment Health Clinic (particularly DOT-CDL medical exams).

IFEHC declares all documents on this page (as well as on this website), even modifications to existing documents, intellectual property to the extent that unique formatting and our supplemental content are enforceable.

Importantly, please note the following. In accepting services, you implicitly consent to the applicable policies. In continuing to seek services, you implicitly consent to any updates to policies.

IFEHC reserves the right to request 100% Refundable Deposit

Since November 1, 2021; IFEHC has announced the right to collect 100% refundable deposits. To date, IFEHC's Medical Director has not enforced this rule. He does not foresee doing so in the immediate future. However, please be advised IFEHC has the right to enforce this rule at any point. If, for instance, the Medical Director is out of town; it is reasonable to expect to be assessed a 100% refundable deposit if the Medical Director changes his plans to accommodate your schedule.

Click the link below for details.

100% Refundable Deposits

Acknowledgment of Policies

IFEHC reserves the right to request 100% Refundable Deposit

Service Agreement for Free Clinics

In response to feedback from patients and examinees, IFEHC has simplified the check-in process. We give one document that indicates acknowledgment (and consent to) the major documents given. This document replaces the Acknowledgment of the Notice of Privacy Practices.

The documents that are being acknowledged can be accessed on this page. In addition, you can reach IFEHC at any of the contact information on the Contact page. To the best of IFEHC's means, it will accommodate requests for alternate formats such as large type and translations. If you are an established patient/examinee; you should always contact IFEHC if you have questions, concerns, or wish for clarifications otherwise.

Acknowledgment of Policies

Service Agreement for Free Clinics

Notice of Privacy Practices (Summary)

Service Agreement for Free Clinics

Service agreement to receive pro bono (free with no expectation of compensation) services. These are in the form of the Adult Internal Medicine Clinic and the Employment Health Clinic.

In signing this document, you consent to the terms and conditions set forth in the other documents on this page. All efforts will be made to obtain your signature. However, failure to obtain your signature does NOT make the other documents inapplicable.

Be advised that committing any crimes on premises, including the use of fraud to obtain services, effectively nullifies any expectations you have from signing the contract or any other document referenced. Good faith belief of such crimes is grounds for IFEHC to investigate and involve appropriate third parties.

Service Agreement

Privacy Practices

Notice of Privacy Practices (Summary)

IFEHC complies with all applicable privacy laws. However, be advised that there are exceptions prescribed by statutes. They specify circumstances when there is a duty to discloseto other parties (e.g., the employer or the public) need-to-know information. Should such a circumstance arise, IFEHC will make all efforts to limit the scope of information disclosed to what is legally required. To access IFEHC's Privacy policy, click the link below. For additional questions, reach the HIPAA Compliance Officer at HIPAA@IFEHC.com.

Privacy Practices

Notice of Privacy Practices (Summary)

This document is a summary of Document #134: IFEHC's Privacy Practices Policy. Patients (or their representatives) must sign an acknowledgement of receiving and understanding this policy (Document #136) in order to receive services. Please be advised that; if you are applying for a DOT-CDL medical card, the FMCSA-NRCME has its own electronic portal and policies governing the storage of your data. IFEHC also draws to your attention that this version grants IFEHC additional authority to cooperate with regulators, law enforcement, and any other third party with legitimate interest. In particular, this revision states that crimes that are committed to influence outcomes are exempt from HIPAA. For additional questions, reach the HIPAA Compliance Officer at HIPAA@IFEHC.com.

Notice of Privacy Practices (Summary)

Release from Liability

Screening Questionnaire

Release from Liability

Idaho Falls Employment Health Clinic, PLLC, or iFEHC, provides its services pro bono. This means free without the expectation of compensation (as opposed to low-cost or affordable). If you seek services, you agree to release IFEHC from liability from circumstances that are outside IFEHC's control.

Release from Liability

Contact Information

Screening Questionnaire

Release from Liability

IFEHC asks you provide contact and emergency contact information.

Contact Information

Screening Questionnaire

This is a link to Document #305: Adult Internal Medicine Screening Questionnaire. It is recommended to complete this questionnaire before free clinic - adult internal medicine encounters. This questionnaire is intended exclusively for screening, not for obtaining details. Thus, many questions are not asked. During the encounter, the Medical Director will focus on areas that need elaboration. Contact IFEHC to receive an encrypted version that can be submitted securely by e-mail to IFEHC.

Screening Questionnaire

Telehealth Consent

Consent for Neuropsychological Testing

Screening Questionnaire

Telehealth is the provision of healthcare using communications technology. Informed consent for receiving telehealth services. Overview of responsibilities of physician and patient. In-person appointments are strongly encouraged over telehealth visits.

You are strongly advised to have as much objective information available as possible. This includes temperature, blood pressure, and pulse. Most pharmacies offer free use of sphygmomanometers (blood pressure cuffs).

Telehealth Consent

Consent for Neuropsychological Testing

You must sign this form in order to receive neuropsychological testing. Examinees are required to view it at least 24 hours before the start of the scheduled encounter.

Neuropsych Testing Consent

CoVid19 Screening

Consent for Neuropsychological Testing

During the peak of the novel coronavirus (CoVid19) outbreak, IFEHC will take all possible measures to reduce clinic volume. If IFEHC agrees to schedule a physical exam, the examinee needs to answer basic CoVid19 screening questions to assess for risk.

COVID19 Screening

Specific to Employment Health (DOT-CDL) Free Health Clinic

Getting Started: DOT-CDL Physical Exams

We have noticed that it can be slightly overwhelming for people getting a DOT-CDL physical examination, especially if people have not had an exam before.

Again; effective November 1, 2021; new examinees will generally be assessed a 100% refundable deposit of $50.

Prepare for DOT-CDL Exam

DOT-CDL Study Guide

Getting Started: DOT-CDL Physical Exams

Go to the Resources section of this menu (Patients) for a study guide on the DOT-CDL physical examination process. Or click below for a link to the document.

DOT-CDL Study Guide

DOT-CDL MERF Questionnaire

Getting Started: DOT-CDL Physical Exams

DOT-CDL MERF Questionnaire

Get started by completing the DOT-CDL MCSA-5875 Medical Exam Report Form (MERF). To make the form interactive (fillable), click the download button. You are advised to request an encrypted form if you wish to e-mail the completed questionnaire.

Form MCSA-5875

DOT-CDL MEC (Encrypted)

List of DOT-Certified SAPs

DOT-CDL MERF Questionnaire

This file, MCSA-5876, is for the use of personnel only. It is encrypted.

Form MCSA-5876

List of DOT-Certified SAPs

This document is NOT applicable for most employment health holders. It is a resource for individuals who are looking for Substance Abuse Professionals (SAP's). Those people are exclusively those who fail DOT drug tests or have been mandated by their employer to seek assistance.

List of DOT-certified substance abuse professionals. Accessed from NAADAC's directory on September 7, 2021. According to NAADAC: "[T]he following directory lists people who have successfully obtained the U.S. Department of Transportation's Substance Abuse Professionals (SAP) Qualification through NAADAC's Substance Abuse Professional's U.S. DOT Alcohol and Drug Testing Regulation Qualification Independent Study Course."

Disclaimer that IFEHC does NOT endorse the contents of this directory. Because IFEHC cannot routinely update the list, we recommend you check NAADAC directly to verify the provider is still listed and confirm with the provider when scheduling an appointment. Are you a new DOT-certified SAP serving the non-Coastal West who wants to be listed? Contact IFEHC (info@IFEHC.com)!

Additional comment: it should be rare that anyone other than employers or other healthcare professionals needs this list. SAP's apply when an individual has failed a DOT drug screen. It is the employer's legal obligation to provide a copy of this list. If your employer tells you to go to an SAP but does not provide a list of SAP's, we suggest seeking legal counsel.

DOT SAP's

Respirator Questionnaire

List of DOT-Certified SAPs

The following is the OSHA questionnaire for using a respirator. Simply complete it and submit it. Click the download button on the PDF to access the interactive (fillable) form. You are advised to request an encrypted form if you wish to e-mail the completed questionnaire.

OSHA Respirator Questionnaire

Specific to Adult Internal Medicine Free Health Clinic

100% Refundable Deposit

Again; effective November 1, 2021; new patients to our free (as opposed to affordable or low cost) health clinic-adult internal medicine will generally be assessed a 100% refundable deposit of $15.

IFEHC's free health (as opposed to low-cost or affordable) clinics comply with applicable laws.

Intake Questionnaire

100% Refundable Deposit

Provide general information about why visiting and pertinent information about medical history.

Intake Questionnaire

Therapeutic Contract

Idaho Board of Pharmacy (IBOP)

IFEHC's Medical Director recently decided IFEHC's Free Health Clinic-Adult Internal Medicine can prescribe controlled substances in limited circumstances. IFEHC's Medical Director and Compliance Officer determined that IFEHC must require anyone taking controlled substances to enter into a therapeutic agreement. Therapeutic contracts are advised by most states' Boards of Pharmacy. This document is publicly available and made known any time prescriptions for regulated substances are made. Thus, all that signing this document shows is that you are acting in good faith. A lack of signature does not vindicate you from the consequences of violating this agreement.

We draw a few additional points to your attention. Your HIPAA rights are substantially restricted. Part of prescribers' responsibilities is to cooperate with government agencies and/or law enforcement in efforts to curb abuse. Although you are entitled to certain privacy protections, those protections fall outside HIPAA. In addition; in IFEHC's interpretation, HIPAA does NOT apply to access of information. You will not be permitted access to any regulatory reports unless regulators mandate IFEHC disclose them. In addition, IFEHC produces screening documents that it regards in the public's interest. For the reason that such screening is designed to protect the public (viz, disclosure could compromise surveillance efforts), this/these document(s) are not considered part of the designated record set (DRS). Under most circumstances, these will not be released as part of medical records requests.

In summary; Idaho Falls Employment Clinic, PLLC, or IFEHC believes strongly in the importance of building trust with patients, putting their interest first, and taking all possible steps to advocate for them. However, IFEHC believes in doing so within the confines of the law and that its obligations last as long as fundamental terms of contract have not been violated. To this effect, IFEHC makes known it is eager to develop a reputation among the regulators and the community in general for strictly enforcing applicable laws and making all good faith efforts to protect the public at large.

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Therapeutic Contract

Idaho Board of Pharmacy (IBOP)

For your convenience, we provide a link to the webpage of the Idaho Board of Pharmacy (IBOP). Should we discover any violations within the jurisdiction of IBOP, we plan to report them to their compliance officers.

IBOP Website

IFEHC's Consumer Policies