Public Works Department
Maintenance Divisions
SAMPLE DOCUMENT – DO NOT PRINT. THIS DOCUMENT IS FOR
INFORMATION ONLY. 2017-18 DOCUMENT TO DOWNLOAD AND
PRINT WILL BE AVAILABLE IN SEPTEMBER
TERMS FOR SNOW BERM REDUCTION PROGRAM for winter 2016-2017
As you know, each year we compile a list of citizens in the City of Post Falls who are unable to
remove the berm that is left in front of their driveway when snowplowing is done. We do not
remove the whole snow berm. Due to time constraints, we only reduce the berm to a passable berm
size for emergency purposes. Homes in cul de sacs will not need curbside markers.
Enclosed are: 1) Instructions, and 2) Medical Information Release and Doctor Statement Form. In
order for a household to qualify for the City of Post Falls Snow Berm Reduction Program, ALL
members of the household must submit all of the enclosed forms. If you need additional forms
for other members of your household, you may pick them up at City Hall or visit the City’s website
at www.postfallsidaho.org. If you need help with your snow berm reduction, you must have these
forms filled out completely by you and your Doctor (M.D. or D.O.) and returned to City Hall.
Applicants must understand that the Medical Information Release and Doctor Statement Forms will
expire at the end of the snow season.
This Instruction Form and Medical Information Release and Doctor Statement Form can be sent
to us by you or your Doctor (M.D. or D.O.) in the following manner:
1. Mail to:
2.
Fax to:
P.W. Maintenance Division, Attn: Kathy
408 N. Spokane Street, Post Falls, Idaho 83854, or
208-777-2840, Attention: Kathy
Please return this signed Instruction Form and the Medical Information Release and
Doctor Statement Forms to City Hall Public Services by the deadline, November 1,
2016, for a guaranteed marker. We will install a curbside marker at each qualified household so
that our snowplow operators can quickly identify homes that are on our list for snow berm
reduction. It is recommended that you follow up on your Forms by contacting Kathy to confirm that
she received them.
Please understand that this is a courtesy and is not a funded program. We ask for your
patience during snowplow operations. The berms are normally reduced during snow removal
operations for your street, time permitting. If you have any questions, please call during normal
business hours at: 773-1722 Monday-Friday, 7:00 am to 3:30 pm.
Your forms will be returned if not fully completed. You must reside at the address given. Penalties
for misrepresentation—I certify that I have read and agree with the Terms.
Signature of Applicant
SAMPLE DOCUMENT – DO NOT PRINT. THIS DOCUMENT IS FOR
INFORMATION ONLY. 2017-18 DOCUMENT TO DOWNLOAD AND
PRINT WILL BE AVAILABLE IN SEPTEMBER
Public Works Department
Maintenance Divisions
CITY OF POST FALLS SNOWBERM REDUCTION PROGRAM
MEDICAL INFORMATION RELEASE AND DOCTOR STATEMENT FORM
PATIENT’S PRINTED NAME:
PATIENT’S ADDRESS:
PHONE:
I hereby authorize my Doctor of Medicine (M.D.) or my Doctor of Osteopathy (D.O.) to release to the
City of Post Falls information regarding my medical condition which relates to my ability to shovel snow.
This authorization will expire at the end of the snow season.
I have read and understood the following:
 I may revoke this authorization at any time prior to its expiration date or event by notifying the
providing person/organization in writing, but revocation will not have any effect on any actions the
entity took before it received the revocation.
 Only the following may be conditioned upon this Authorization being provided:
1. Research–related treatment.
2. Enrollment in the health plan or eligibility for benefits when relating to underwriting or risk
rating determinations and the request is not for psychotherapy notes.
3. Health care that is solely for the purpose of creating protected health information for disclosure
to a third party.
 Disclosure of this information by an entity subject to HIPAA privacy regulations to a person/entity may
be subject to re-disclosure by the recipient without my further authorization.
Dated:
Patient Signature (required)
AS THE DOCTOR OF MEDICINE (M.D.) or DOCTOR OF OSTEOPATHY (D.O.) FOR
I AFFIRM THAT THE PATIENT HAS A
MEDICAL CONDITION/DISABILITY THAT PROHIBITS HIS/HER ABILITY TO REMOVE SNOWS
CREATED BY A PLOWED BERM.
M.D. or D.O.’s PRINTED NAME (required)
M.D. or D.O.’s SIGNATURE (required)
(Doctor must sign)
M.D. or D.O.’s ADDRESS (required)
408 N. Spokane Street, Post Falls, ID 83854  tel (208) 773-1722  fax (208) 777-2840