NEW PATIENT REGISTRATION FORM

As a Federally Qualified Heath Center, ROADS is required to collect demographic information regarding the patients we serve. The information you provide is confidential. Please check Declined to Specify if you do not wish to answer a specific question. Thank you for choosing ROADS as your healthcare provider.

 

This authorization allows ROADS Providers and staff to communicate information regarding your medical care to the individual(s) you designate. As part of ROADS' Patient Private Policy, ROADS will release your health information only as you specifically authorize. Please check whether you do or do not authorize ROADS to release your health information and complete the form.

 

The Minor Treatment Consent Form gives our providers permission to treat your child when he or she is in someone else's care. Please list the person's name, phone number, and his or her relationship to your child in the spaces provided.

What is sliding scale?

A sliding scale is the method we use to offer discounts on healthcare based on a patient's household size and income.

What happens if I don't apply?

You will be asked to pay the full charges for the services provided if you choose not to apply.

How can I prove my income?

a) Payroll check that shows year to date income

b) Current pay stub from within the past 45 days

c)Current wage statements (written statement from employer)

d) Unemployment check stub from within the past 45 days e)Current bank statement that shows flow of money in/out of account

f) Current statement from Social Security office g)First page of current or previous year income tax forms

h) W2

What if I don't bring proof of income?

You can provide self-attestations of income for up to three visits with ROADS Community Care clinic to be eligible fora sliding scale discount without proof of income. After 3 visits, if you do not provide additional proof of income, your visits will be billed at full fee.

Does the sliding scale change my insurance co-pay, deductible or co-insurance amount?

No, if your insurance company requires that you pay a certain amount as a co-pay, deductible, or coinsurance for your services, you may receive a greater discount by applying for the Sliding Fee Discount Program. You will be requested to pay either the discounted amount based on your sliding fee eligibility or what you would pay within your insurance coverage, whichever is less. Exceptions may apply, such as if your insurance prohibits discounting your share of cost.

What if this information changes?

If your income or household size changed, please inform the receptionist. You will be asked to fill out a new application and show proof of new income. Sliding scale rate is valid for 1 year with proof of income.

Agreement of Financial Responsibility

Thank you for choosing us as your health care provider. We are committed to providing quality care and service to all our patients. The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment:

Please understand that payment of your bill is considered part of your treatment. Fees are payable when services are rendered. We accept cash, check, credit cards, and pre-approved insurance for which we are a contracted provider and are the designated Primary Care Provider (PCP), if applicable.

It is your responsibility to know your own insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any pre-authorization requirements of your insurance company.

We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.

If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible(s), and then bill you for any amount determined to be your responsibility. This process generally takes 45-60 days from the time the claim is received by the insurance company.

If we do not contract with your insurance company, you will be expected to pay for all services rendered at the end of your visit. We will provide you with a statement that you can submit to your insurance company for reimbursement.

Proof of payment and photo ID are required for all patients. We will ask to make a copy of your ID and insurance card for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company.

Please understand some insurance coverages have Out-of-Network benefits that have co- insurance charges, higher co-payments and limited annual benefits. If you receive services are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the in-Network rate.

Patient Bill of Rights and Responsibilities

The ROADS FOUNDATION is happy to have you as our patient. We are committed to treating you with consideration and respect, honoring your legal rights, and working to meet your health care needs. In order to make this a mutually beneficial and positive experience and to help our skilled and caring staff to treat you, we have listed your rights and responsibilities as a patient at The ROADS FOUNDATION.

You Have the Right to:

• Take part in your health care treatment.
• Know the names of the people caring for you.
• Be treated with respect and dignity in a safe and private setting.
• Be informed about your illness and treatment, including options for your care.
• Request a change of medical providers.
• Get another opinion about your illness or treatment.
• Privacy of your health records.
• Have a cultural, social, spiritual and personal beliefs respected.
• Know about legal reporting requirements.
• An interpreter if you have any difficulty hearing, speaking or understanding English.
• Ask for special and reasonable accommodation if you have a disability.
• Ask for help with a living will or durable power of attorney for health care.
• Refuse treatment, care and services as allowed by law.
• Know the cost of your care and ways you may pay your care.
• Talk in person with a The ROADS FOUNDATION manager if you have a complaint.
• It is the policy of The ROADS FOUNDATION to afford its patients the opportunity to pursue a resolution to any concerns in a structured format that provides fair and equitable process. Bring concerns in writing to the Patient Grievance Committee, 121 S. Long Beach Blvd. Compton, CA 90221.

The ROADS Foundation Agrees to:

• Provide health care to anyone in need regardless of ability to pay.
• Offer a sliding fee discount for uninsured and under-insured patients who earn less than 200% of the Federal Poverty Level and for those who are homeless.
• Inform you about the services we offer. 
• Provide timely care, within our resource constraints.
• Provide clear diagnosis and treatment options when we can and be frank with you when we don't know or aren't sure.
• Provide clear boundaries with respect to the care we will provide to you and treatments we don't advise or will not do.
• Value you as a patient and person.

 You Have the Responsibility to:

• Take part in your health care treatment.
• Give us information so that records are accurate and complete.
• Help us get a copy of your health records from your past providers if needed.
• Tell your health provider about your illness or problems.
• Ask questions about your illness or care.
• Arrive for appointments ahead of the scheduled time.
• Cancel or reschedule appointments so that another person may have that time slot.
• Use medications or medical devices as prescribed and for yourself only.
• Inform the medical provider if you become worse or have an unexpected reaction to a medication.
• Call at least two working days ahead to refill your prescription.
• Respect the privacy of other patients.
• Speak and behave respectfully to all staff, patients, and visitors.
• Pay your bills on time, or if you're having difficulty, arrange a payment plan.

 

A Patient-Centered Medical Home is a trusting partnership between a provider-led healthcare team and an informed patient. It includes an agreement between the provider and the patient that acknowledges the role of each in the total healthcare program.

 As your primary care provider, we will:

• Learn about you, your family, life situation, and health goals and preferences. We will remember your health history every time you seek care and suggest treatments that make sense to you.
• Take care of short-term illness, long-term chronic disease, and your all-around well-being.
• Keep you up to date on all your vaccines and preventive screening tests.
• Connect you with other members of your care team (specialists, behavioral healthcare, etc.) and coordinate your care with them.
• Be available to you after hours for your urgent needs (per Practice Information sheet)
• Notify you of test results in a timely manner.
• Communicate clearly with you so you understand your condition(s) and your care plan.
• Listen to your questions and feelings. ROADS will respond promptly to you in a way you understand.
• Help make the best decisions for your care.
• Give you information about classes, support groups, or other services that can help you learn more about your condition and stay healthy.

 We trust you, as our patient, to:

• Know that you are a full partner in your care.
• Come to each visit with any updates on medications, dietary supplements, or remedies you’re using and questions you may have.
• Let us know when you see other health care providers so we can help coordinate the best care for you.
• Keep scheduled appointments or call to reschedule or cancel as early as possible.
• Understand your health condition, ask questions about your care, and tell us when you don’t understand something.
• Learn about your condition(s) and what you can do to stay as healthy as possible.
• Follow the plan that we have agreed is best for your health.
• Take Medications as prescribed.
• Call if you do not receive your test results within 2 weeks.
• Contact us after hours only if your issue cannot wait until the next day.
• If possible, contact us before going to the emergency room or urgent care.
• Learn about health insurance coverage and contact ROADS if you have questions about your benefits.
• Pay your share of any fees.
• Give us feedback to improve our care for you.

We look forward to working with you as your Primary Care Provider in your Patient-Centered Medical Home.

• Complete the Medical History Fact Sheet and bring with you to your appointment. Be sure to include the names, addresses and phone numbers of other health care providers you have visited. The practice functions most effectively as a medical home if patients provide a complete medical history and information about care obtained outside the practice.
• Make a list of your health questions. Ask a friend or relative for help if you need it. Put the questions that are most important at the top of the list. Your provider may not be able to address everything at one visit but will prioritize based on your current health and medical conditions.
• Bring all your medications in their original containers to your appointment. Be sure to include prescription, over the counter, natural, and herbal medicines and vitamins.
• Bring your current insurance card(s) and photo ID with you.
• If you wish, ask a family member or trusted friend to go to your appointment with you.
• Plan to arrive at least 15-20 minutes prior to your scheduled appointment time to complete thenew patient check-in process.

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

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

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
• 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

• You can complain if you feel we have violated your rights by contacting us using the information.
• 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
• Contact you for fundraising efforts

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 run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and 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

Help with public health and safety

• 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
-Preventing or reducing a serious threat to anyone's health or safety violence

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

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 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.

Consent to Treatment and Consent to Release Health Information

For Treatment, Payment, and Health Care Operations

I hereby give my consent for treatment for myself, or the named patient (of whom I am the parent or legal guardian who has the right to consent to treatment for the named patient) to The ROADS Foundation. Treatment may include health screening, diagnosis, medical treatment, dental care: social services; and/or mental health and drug and alcohol screening, assessment, diagnosis and treatment.

Consent to Release of Health Information, including Health/Treatment Records for Treatment, Payment and Health Care Operations

I consent to the use within The ROADS Foundation and the disclosure to persons or organizations outside of The ROADS Foundation of my (or of the named patient for who I am the parent or legal guardian) medical, dental, drug and alcohol, mental health and other treatment and health records and information (such health records and information are referred to in this Consent as my "Health information") by The ROADS Foundation for the following purposes;

a) Use of Health Information by or for The ROADS Foundation for treatment and for Health Care Operations: Providing treatment by The ROADS Foundation staff: Conducting health care operations of The ROADS Foundation including, for example, financial or quality assurance audits and training

b) Disclosure of Health Information to Persons Outside The ROADS Foundation for treatment purposes and for payment Providing all necessary Health Information as determined by The ROADS Foundation, including information about treatment for drug or alcohol abuse, to any health providers if I am referred there for

Providing Health Information to other health providers or agencies who may be involved in my care Obtaining payment for health care bills, including sending such Health Information as is needed to secure payment for The ROADS Foundation services to the insurance company or agency that pays for my health services, as identified in my Registration Form or other updated insurance information on file with The ROADS Foundation.

Other Matters

• I understand that I have the right to revoke this Consent at any time but revoking this Consent will not affect any actions which were taken by The ROADS Foundation in reliance on this Consent before I revoked it. If not previously revoked, this consent will terminate on the following date, event, or condition: If none is indicated, this consent will terminate three years after the last date of services to me.
• I understand that I may request restrictions on use or disclosure of my Health Information for the purposes described in this Consent and The ROADS Foundation may or may not agree to the requested restrictions. I also understand that except for those restrictions on use or disclosure of Health Information to which it agrees, The R.O.A.D.S Foundation will not be able to provide services to me (or the named patient) without this signed Consent. I understand and acknowledge that I am financially responsible for any unpaid balances incurred as a result of my care at The ROADS Foundation.

ROADS prohibits all persons who enter ROADS Community Clinic's property from carrying a handgun, firearm, or prohibited weapon of any kind onto the clinic premises. This policy and its prohibitions apply to all ROADS Community Clinic's employees, contract and temporary employees, students, patients, and visitors entering the property for any reason. The only exceptions to this policy are Law Enforcement Officers as defined by state law. "Weapons" which are not allowed on the clinic's premises include any form of weapon or explosive restricted under local, state, or federal regulations. This includes all firearms, illegal knives or other weapons covered by the law. If you become aware of anyone violating this policy, please report it to management staff immediately. If a person is discovered to be in possession of a firearm or other weapon, Security will retrieve the firearm/weapon and place in secured locker. If person refuses to allow Security to take control of the firearm/weapon, the police department will be notified. Signs are posted at all entrances of the clinic announcing the clinic's policy prohibiting firearms and other weapons on the clinic premises.

If you are experiencing a life-threatening emergency, please call 911. Should you need to reach your Doctor or Clinician after hours, call our offices at 310-627-5850 or 855-645-0033, and our 24 hour live answering service will contact the physician on your behalf.

If you are experiencing a life-threatening emergency, please call 911. Should you need to reach your Doctor or Clinician after hours, call our offices at 310-627-5850 or 855-645-0033, and our 24 hour live answering service will contact the physician on your behalf.

CONSENT

Signing the consent form means that you are allowing your own electronic health information to be used by health care providers at participating centers and clinics only to provide you with medical treatment and support public health projects.
Sharing your own electronic health information in a health information exchange is your choice. The health care providers will provide you with medical care even if you decide not to share your own electronic health information in the health information exchange. Your insurance eligibility will not change based on your decision to share your own electronic health information in the health information
exchange.

PURPOSE
Sharing your own electronic health information will allow your health care provider to review all of your
medical history and treatments. This will help your health care provider to make better informed decisions
about your medical care.
Some benefits of sharing individual health information electronically may be:
• Improved communication among your health care providers, and
• Fewer unneeded tests and treatment.
Some risks of sharing your own health information electronically may be:
• Someone seeing your individual health information who is not providing you with medical
treatment or supporting public health projects, and
• Someone stealing your health information by entering the health information exchange illegally.

TYPES OF INFORMATION INCLUDED IN THIS CONSENT

If you give consent, any participating HIE organization may view and share ALL of your electronic
health information available through any connected health information exchange. This includes
information created before and after the date of your consent form. Your health records may include a
history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like x-rays or
blood tests), and medicines you have taken. This information may relate to sensitive health conditions,

including but not limited to:
• Alcohol or substance abuse records
• Birth control, abortion, and family planning
• Inherited or genetic conditions
• HIV
• Mental health conditions
• Sexually transmitted diseases
• Lab results