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.
Section 3: Additional Information
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.
I, blanks the legal parent/guardian of First Name Last Name (Minor's Name), grant permission to the following individuals(s) to request and approve medical care for the above named minor:
Are you homeless /Doubling Up? Yes No* Do you live /work in Los Angeles County? Yes No* Are you a college/university student Yes No* Are you a tourist or foreign student? Yes No* If yes, can you be claimed as a dependent on someone else's tax return? Yes No* (If yes, additional income verification required)
Income calculation * Total Household Members from Section 1 & 2
* Wages/Salary $ 0* per year* = $ 0* Self-employment $ 0* per year* = $ 0* Unearned $ 0* per year* = $ 0* TOTAL Annual Income $ 0* Specify Type
By signing below, I give permission to THE ROADS FOUNDATION to share this document and any attachments with THE ROADS FOUNDATION for the purposes of enrollment in its sliding fee schedule. I understand this sharing of information may decrease any out-of-pocket cost to me for services ordered and performed at THE ROADS FOUNDATION (e.g., laboratory testing I also understand that I may revoke this permission by writing "do not share" next to my signature and that signing this document is not a condition of receiving treatment at THE ROADS
To the best of my knowledge, the above information is true and correct. I agree to inform THE ROADS FOUNDATION of any changes in my employment or financial status. If the above information proves to be incorrect, I understand that the discount provided to me will be terminated.
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:
The ROADS Foundation Agrees to:
You Have the Responsibility to:
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:
We trust you, as our patient, to:
We look forward to working with you as your Primary Care Provider in your Patient-Centered Medical Home.
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.
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
Ask us to correct your medical record
Request confidential communications
Ask us to limit what we use or share
*We are not required to agree to your request, and we may say "no" if it would affect your care.
*We will say "yes" unless a law requires us to share
Get a list of those with whom we've shared information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you feel your rights
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:
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:
In the case of fundraising:
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.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
Bill 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
-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
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
Address workers' compensation, law enforcement, and other government requests
-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
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.
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.
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
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
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.
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.
PURPOSESharing 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