Consent for Treatment and Acknowledgements

To become a patient and receive treatment, we need your consent to provide care. We also need you to acknowledge that we have provided you with certain important information and documents. If you have any questions about any of this information, please do not hesitate to ask a member of our staff. By signing, you are indicating that you understand the information, have been given a chance to ask questions, and are giving your consent.

General Consent to Treat

I voluntarily agree to receive services from Universal Community Health Center (UCHC), and authorize the providers of Universal to provide such care, treatment, or services as are considered necessary and advisable for me. I understand that I should participate in the planning for my care and that I have a right to refuse interventions, treatment, care, services or medications at any time to the extent the law allows. I understand that the care I will receive may include tests, injections, and other medications, etc. that are based on established medical criteria, but not free of risk.

Notice of Privacy Practices

I understand that, under the Health Insurance Portability and Accountability Act of 1998 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations.

I acknowledge that I have read Universal's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Universal has the right to change its Notice of Privacy Practices at times and that I may request a current copy of the Notice of Privacy Practices at any time.

Health Information Exchange

I understand that Universal participates in certain health information exchanges with other health centers and hospitals located in Los Angeles area. Your health information may be shared with these exchanges to provide faster access, better coordination of care, and to assist providers and public health officials in making more informed decisions. Please notify Universal if you wish to "opt-out" and disable access to your health information, except to the extent that disclosure of such information is permitted or mandated by law.

Release of Information for Billing and Consent to Reimburse

I know that Universal needs to send parts of my personal health information to organizations that help pay for my care, such as insurance payers or organizations that grant money to Universal. I allow Universal to release the relevant parts of my records so that my care can be paid for. If I do not feel comfortable with this, then I understand that I can request a higher level of privacy protection than is afforded to me under the Health Insurance Portability and Accountability Act (HIPAA).

Acknowledgment of Duty to Reimburse Universal for Health Care Services

I understand that Universal offers a Sliding Fee Scale of discounted or free health care items and services to individuals who are deemed unable to pay based on their level of income. To become eligible for Universal's Sliding Fee Scale of discounted services, I will need to provide Universal staff with documents establishing that I meet income eligibility requirements which include proof of income and family size. If I do not provide the required documents to Universal, I am responsible for paying my fees for medical, behavioral health, or dental services received at Universal in full at the time of service.

By signing my name below, I am acknowledging that I have read and understand each of the separate paragraphs set forth above.

Patient Acknowledgement of Financial Responsibility

In order to maintain our fees at the lowest possible level, it is important that we have a good understanding with our patients regarding financial responsibility. We hope that this summary will be helpful toward that end. We encourage you to discuss it with us and to ask questions.

You must pay any co-payment and applicable deductible amounts at the time of service unless other arrangements have been made with our office. If you are not insured, or if the services being provided are not covered by your insurance, you will be expected to provide payment in full for our services at the time they are rendered. The remainder of your bill will be sent to your health plan for direct payment to our office. In those instances where we have a participating provider agreement with your insurance company for an agreed-upon negotiated rate for our services, an adjustment will be made in the amount of the difference between this rate and our normal fees at the time we receive payment from your insurance company. You will remain responsible for required copayments, applicable deductible amounts and any services that are not covered by your insurance plan. If, by mistake, your health plan remits payment to you, please send it to us along with all paperwork sent to you at the time. Your health plan may refuse payment of a claim for some of the following reasons:

1.This is a pre-existing illness that is not covered by your plan

2. You have not met your full calendar year deductible 3. The type of medical service required is not covered by your plan 4. The health plan was not in effect at the time of service

5. You have other insurance which must be filed first

Please understand that financial responsibility for medical services rests between you and your health plan. While we are pleased to be of service by filing your medical insurance for you, we are not responsible for any limitations in coverage that may be included in your plan. If your health plan denies this claim for any of these or other reasons, our office cannot be responsible for this bill. It is your responsibility as the patient to pay the denied amounts in full.

Our primary mission is to provide you with quality, cost-effective, medical care. Together we are trying to adapt to the changing way that healthcare is financed and delivered. Again, we value you as a patient and our first priority is to provide you with the best possible care.

I have read and understand my obligations and I acknowledge that I am fully responsible for payment of any services not covered or approved by my insurance carrier.

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights - You have the right to:

Get a copy of your paper or electronic medical record. Correct your paper or electronic medical record. Request confidential communication. Ask us to limit the information we share. Get a list of those with whom we’ve shared your information. Get a copy of this privacy notice. Choose someone to act for you. File a complaint if you believe your privacy rights have been violated. 

Your Choices - You have some choices in the way that we use and share information as we: Tell family and friends about your condition. Provide disaster relief Include you in a hospital directory. Provide mental health care Market our services and sell your information. Raise funds Our Uses and Disclosures 

We may use and share your information as we: 

Treat you. Run our organization. Bill for your services. Help with public health and safety issues. Do research. Comply with the law. Respond to organ and tissue donation requests. Work with a medical examiner or funeral director. Address workers’ compensation, law enforcement, and other government requests. Respond to lawsuits and legal actions. 

Your Rights: When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days. 

Request confidential communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. Ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. 

Get a copy of this privacy notice - You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. 

Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated. You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint. 

Your Choices - For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care. Share information in a disaster relief situation. Include your information in a hospital directory. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases, we never share your information unless you give us written permission: Marketing purposes, Sale of your information, Most sharing of psychotherapy notes. 

In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again. 

Our Uses and Disclosures - How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you - We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. 

Run our organization - We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. 

Bill for your services - We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. 

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues. We can share health information about you for certain situations such as: Preventing disease, Helping with product recalls. Reporting adverse reactions to medications, Reporting suspected abuse, neglect, or domestic violence. Preventing or reducing a serious threat to anyone’s health or safety. Do research. We can use or share your information for health research. Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests. We can use or share health information about you: For workers’ compensation claims, For law enforcement purposes or with a law enforcement official, With health oversight agencies for activities authorized by law, For special government functions such as military, national security, and presidential protective services. Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena. 

Our Responsibilities 

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We never market or sell personal information. We will never share any substance abuse treatment records without your written permission. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 

For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html 

Changes to the Terms of this Notice 

We can change the terms of this notice, and the changes will apply to all the information we have about you. The new notice will be available upon request, in our office, and on our website.