Welcome to FHCCGLA

General Consent for Treatment Form

GENERAL CONSENT FOR TREATMENT

Family Health Care Centers of Greater Los Angeles, Inc. (FHCCGLA) offers primary health care in an ambulatory clinic setting. Our focus is preventive health services that are preventive in nature, including pediatric services, prenatal care, family planning, breast and cervical cancer screening and treatment of certain sexually transmitted diseases. A referral service is provided for clients whose concern is not within the scope of practice defined by FHCCGLA.

FHCCGLA clinics, Bell Gardens Family Medical Center (BGFMC), Hawaiian Gardens Health Center (HGHC), Downey Family Medical Center (DFMC), Maywood Family Medical Center (MFMC) and School Base Health Center (SBHC) participate in health care subsidized programs offered by the federal, state, and county governments and managed care programs. As a condition of these programs, client’s chars are reviewed and evaluated for quality and program compliance. However, information regarding a single client requires the notification and consent of the client for release unless requested by court subpoena.

  • I understand that I have the right to be treated with dignity and respect.
  • I understand that I will receive explanations to any questions, have privacy and confidentiality of my records and have the ability to review records with a clinician.
  • I understand that I have the right to refuse any care of treatment at any time.
  • I understand that I am responsible to follow health advice, medical instructions, to be honest regarding my medical history, and to report any significant changes in my health to the clinic
  • I have the right to make a complaint about treatment or events that take place within the clinic. I have the right to have a fair hearing regarding such complaints. A procedure for such hearing will be explained to me.

Under the conditions stated, I consent to the examinations and laboratory tests considered necessary for my health and to the confidential release of my medical records for FHCCGLA.

Authorization is effective immediately and is to continue in effect until withdrawn in writing.

  • Date Format: MM slash DD slash YYYY
  • (If Applicable)

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This resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $2,933,524 with 60% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.