Snake River Community Clinic

Available Forms

Dental Care Request Medication Refill Request Form Patient Health Questionnaire - Depression Screening Patient Intake/pre-appointment Form Self-Attestation Income Verification

Medication Refill Request Form

Date of Request

Patient Name *

Patient's Date of Birth *

Phone Number *

Address

CHECK HERE IF YOU WANT US TO MAIL YOUR MEDS.

Please make sure we have your current correct address

Medication Pick up

Refills can be picked up Monday and Wednesday from 10AM - 4PM; Thursday 5PM - 7:30PM

Pick up date request

Pick up time request

Medications Requested *

Medications not listed will not be filled

SRCC, P.O. BOX 6, Lewiston, ID 83501

Notice of Limited Liability of FTCA Deemed Free Clinic Health Care Professionals

This is to notify you that under Federal law relating to the operation of free clinics, the Federal Tort Claims Act (FTCA), (See 28 U.S.C งง 1346(b), 2401(b), 2671-80) provides the exclusive remedy for damage from personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by any free clinic health care practitioner who the Department of Health and Human Services has deemed to be an employee of the Public Health Service. The FTCA medical malpractice coverage applies to deemed free clinic health care practitioners who have provided a required or authorized service under the Title XIX of the Social Security Act (i.e. Medicaid Program) at a free clinic site or through offsite programs or events carried out by the free clinic (See 42 U.S.C. ง 233(a), (o)). The above Federal law and other State and Federal laws including the Federal Volunteer Protection Act of 1997 and Immunity from liability for healthcare providers providing charitable medical care Idaho Code: 39-7703, may cover certain free clinic health professionals providing health care services to patients at this free clinic.

Patient's Signature *

Please read the above waiver and acknowledge by typing your name here

* Required field