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2019 Patient Registration

Patient InformationLast Name First Name M.I.

DOB (MM/DD/YYYY) Social Security #Gender: Male Female Transgender (M-F)

Transgender (F-M) OtherMailing Address City State ZipPhysical Address City State ZipHome Phone: Cell Phone: Work Phone:OK to leave a message? Home Cell Work None Appointment Reminder: Home Cell Work NoneRelationship Status: Single Married Partner Divorced Separated Widowed Student? Full-Time Part-time NoRace: American Indian/Alaska Native Black/African American Native Hawaiian Asian White/Caucasian Other Pacific IslanderHispanic or Latino origin? Yes No Preferred Language? English Other: Do you need a translator? Yes No

Employer: Status: Full-Time Part-time Reserve Retired Unemployed Active Duty Self-employed

Enroll in Patient Portal? Already enrolled Yes No If yes, your email:Preferred Pharmacy: City:Sexual Orientation: Straight (not lesbian/gay) Lesbian/gay Bisexual Other DeclineHow did you hear about PCHS? Friend/family member Referral Newspaper Internet Radio Community Event OtherType of Residence: : Own Rent Shelter Homeless Friends/Family Transitional Public Housing Migrant Seasonal Other Are you a veteran of the United States Armed Forces? Yes No

Responsible Person (If patient is a minor or other guardian is appointed for adult)Last Name First Name M.I.Mailing Address City State ZipDOB (MM/DD/YYYY) Home Phone: Cell Phone:Employer: Work Phone:Who does patient live with primarily? Both Parents Mother Father Shared Custody Other:

Please provide proof of court-issued guardianship if held by someone other than the patient.Emergency Contact

Emergency Contact Name: Relationship to Patient:Home Phone: Cell Phone: Work Phone:

Annual Income: Circle the number of people living in your household and your household income range on the same line as household size. This information is not associated with the Sliding Fee Discount. Some of our funding comes from grant monies that require patient income information to prove a financial need in the

community. These grants allow us to provide a higher level of care than we could otherwise afford.

Are you interested in applying for the Sliding Fee Discount? Yes No I decline to provide my financial information.

Household or Family Size At or below 100% Between (101%-150%) Between (151%-175%) Between (176%-200%) More Than (Over 200%)1 $15,180 $15,181 - $22,770 $22,771- $26,565 $26,566 - $30,360 $30,3612 $20,580 $20,581 - $30,870 $30,871 - $36,015 $36,016 - $41,160 $41,1613 $25,980 $25,981 - $38,970 $38,971 - $45,465 $45,466 - $51,960 $51,9614 $31,380 $31,381 - $47,070 $47,071 - $54,915 $54,916 - $62,760 $62,7615 $36,780 $36,781 - $55,170 $55,171 - $64,365 $64,366 - $73,560 $73,5616 $42,180 $42,181 - $63,270 $63,271 - $73,815 $73,816 - $84,360 $84,361

**My signature indicates the information provided above is true and correct.**

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/2019Signature (Patient or Responsible Party) Date

/2019Print Name (Patient or Responsible Party) Date


** We bill insurance as a courtesy. Please provide us with a copy of your insurance card(s) as well as the following information. **

Primary Insurance Company None Alaska Medicaid Denali KidCare Medicare Private Insurance Other:

Insurance Company Policy ID# Group #Policy Holder Name (Last, First, M) DOB (MM/DD/YYYY):Patient Relationship to Insured: Self Spouse Dependant Other: SSN:Mailing Address (City, State, Zip)Phone # Alternate Phone #: Employer:

Secondary Insurance Company None Alaska Medicaid Denali KidCare Medicare Private Insurance Other:

Insurance Company Policy ID# Group #Policy Holder Name (Last, First, M) DOB (MM/DD/YYYY):Patient Relationship to Insured: Self Spouse Dependant Other: SSN:Mailing Address (City, State, Zip)Phone # Alternate Phone #: Employer:

Authorization to pay benefits to PCHS: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to myself or to PCHS when PCHS accepts assignment. My signature here indicates the information provided below is true and correct.

** By signing below, you are authorizing PCHS to bill your insurance. **

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/2019Print Name (Patient or Responsible Party) Date


Patient Name: _______________________________________________ Date of Birth: In order to receive treatment, you must sign below acknowledging the following terms. Please ask questions about any area of concern.

Service Agreement Peninsula Community Health Services (PCHS) offers health care using a team of caregivers. Our team members have various

training and skills which they utilize while working together as a team to help meet your health care needs. PCHS has an integrated electronic health record system. Personal Health Information (PHI) is kept in your electronic health record. Your records are accessed by PCHS staff members who are involved in your care. Your records may include information from any of our medical providers, behavioral health providers, dentists, and/or case workers. It may also include reports from various health care providers outside of PCHS.

All health information is kept private between you and your health care professional except in circumstances when disclosure is required or otherwise permitted by law.

PCHS is a community health center, funded in part by state and federal grants. As such, PCHS may be required to release some, or all, of your PHI to satisfy grant-reporting requirements.

Privacy Agreement You have been offered a copy of PCHS’s Notice of Privacy Practices. A copy of PCHS’s Notice of Privacy Practices is posted at

each service location. PCHS takes seriously the protection of your Personal Health Information (PHI) and will only divulge minimum necessary information required to accomplish our purpose.

You may register a complaint or voice a grievance without fear of reprisal. You have been offered a copy of PCHS’s Patient Bill of Rights.

Financial Responsibility All services are billed at a standard rate. PCHS bills insurance as a courtesy. You are responsible for the balance not covered

by insurance or third party payers within 120 days of your service. PCHS accepts assignment on Medicare and Medicaid claims. If you qualify, a sliding-scale discount may be applied to the unpaid balance or any “out-of-pocket” expenses. Discounts are available based on household size and household income.

You agree to pay your fees and/or insurance co-payment and required deductible at the time of service. Any balance on your account after 120 days will be sent to Cornerstone Collections. You authorize a collections agency to contact you directly on your past balance due to Peninsula Community Health Services.

PCHS does not operate a “free clinic.” Regardless of insurance coverage or financial category, you will not be refused services because of an inability to pay, as long as you agree to demonstrate a willingness to pay. Unwillingness to pay may result in your dismissal as a patient. If you fail to provide income verification or family size, you will not be eligible to participate in a sliding discount and will be responsible for 100% of the charges for services rendered by PCHS providers. If you have Medicare or Medicaid, you may not opt out of disclosure of your insurance coverage.

PCHS relies on the fees paid by you and your insurance company to continue to deliver services.

*I have read and agree to the above Privacy Agreement, Service Agreement, and Financial Responsibility.*

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Patient Name: _________________________________________ Date of Birth:

Appointment PolicyWe see patients on an appointment basis and your appointment is reserved exclusively for you. We respect your time and make every effort to remain on schedule; therefore we request that you check-in on time for your appointment.

Arrival time is based on appointment type and is determined by each department. Expected arrival time is communicated to you when you book your appointment.

We understand that circumstances arise that prevent patients from keeping appointments. If you are unable to keep an appointment, please call and cancel or reschedule by 3 pm the day before your scheduled appointment.

We request these accommodations from you as it allows us to see our patients promptly as well as have time to fill cancelled appointment slots.

Our policy states that once a second scheduled appointment is missed within a 12 month period, a notice will be sent alerting you of the consequence of missing the third scheduled appointment within a 12 month period. The consequence is that you (the patient) will only be able to have emergency walk-in care in our Dental Center and schedule same day appointments in our Medical Clinic and Behavioral Health Center. This probationary period will be in effect for 12 months.

A missed appointment is defined as: 1. Calling to cancel or reschedule the appointment after 3 pm the day prior to the scheduled appointment2. An appointment for which the patient arrives too late for the appointment to occur. Patients are required to check-in at the clinic

at the recommended check-in time. Patients checking-in after the recommended check-in time are considered late and will be seen if the provider schedule and remaining time allows for the completion of quality care.

ATTENTION PARENTS AND GUARDIANS: If your child is under 18, the policy requires that you accompany your child to all appointments and remain in the clinic during his/her appointment. Treatment will not begin until a parent or guardian is present.

I have read and understand the above appointment policy for Peninsula Community Health Services.

Designation of Personal RepresentativeThis person(s) may act in place of you for purposes of authorizing use and disclosure of protected health information. For example, he/she may be called by our billing department to answer questions regarding insurance, or called to remind you of upcoming appointments. Please name below the person(s) you would like to have this authority.

Name: OK to discuss: Appointments Billing Other:

Name: OK to discuss: Appointments Billing Other:

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CONDITIONS OF SERVICE AND CONSENT FOR TREATMENT

IMPORTANT: DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS.In consideration of services provided by Peninsula Community Health Services (PCHS), the Patient or undersigned representative acting on behalf of the Patient agrees and consents to the following:

1. Consent to Routine Medical/Dental/ Behavioral Health Treatment/Services

PCHS is dedicated to providing medical, dental, and behavioral health services to Kenai Peninsula residents. Physical and emotional health often go together and we believe the best care is given when health care providers work together. PCHS patients may be referred from other health care specialties within the PCHS treatment team; members of the treatment team may share clinical information with each other as is clinically necessary.

Patient consents to the rendering of Medical/ Dental/ Behavioral Health Treatment/Services (hereafter referred to as “services”) as considered necessary and appropriate by their PCHS healthcare provider. PCHS Services are performed by "Healthcare Professionals" (physicians, nurses, medical assistants, technologists, physician assistants, nurse practitioners, clinicians, dental hygienists or other healthcare professionals). Patient authorizes the healthcare provider/clinicians and PCHS to provide Services ordered or requested by the rendering provider and those acting in his or her place. The consent to receive "Medical/Dental/ Behavioral Health Treatment/Services" includes, but is not limited to: examinations; laboratory procedures; medications; infusions; drugs; supplies; anesthesia; minor surgical procedures and medical treatments; recording/filming for internal purposes (identification, diagnosis, treatment, safety, security) and other services which Patient may receive. In the event PCHS determines that Patient should provide blood specimens for testing purposes in the interest of the safety of those with whom Patient may come in contact; Patient consents to the withdrawing and testing of Patient's blood and to the release of test information where this is deemed appropriate for the safety of others.

2. Legal Relationship between Clinic Locations and Physician/Clinicians

From time to time healthcare professionals performing services at PCHS may be independent contractors and are not PCHS agents or employees. Independent contractors are responsible for their own actions and PCHS shall not be liable for the acts or omissions of any such independent contractor.

3. Explanation of Risk and Treatment Alternatives

Patient acknowledges that the practice of medicine and dentistry are not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO THE PATIENT concerning the outcome and/or result of any Services. While routinely performed without incident, there may be material risks associated with any PCHS Services. Patient understands that it is not possible to list every risk for all Services and that this form only attempts to list the most common material risks and the alternatives (if any) associated with these. Patient also understands that various Health care Professionals may have differing opinions as to what constitutes material risks and alternative Medical/Dental/ Behavioral Health Treatment/Services. By signing this form: Patient consents to Healthcare Professionals performing Medical/Dental/ Behavioral Health Treatment/Services as they may deem reasonably necessary or desirable in the exercise of their professional judgment, including those Services that may be unforeseen or not known to be needed at the time this consent is obtained; and Patient acknowledges that Patient has been informed in general terms of the nature and purpose PCHS Services; the material risks of Services and as may be practical any alternatives to the Medical/Dental/ Behavioral Health Treatment/Services.

Services may include, but are not limited to the following:a) Needle Sticks, such as shots, injections, b) Physical Tests, Assessments and Treatments such as vital signs, internal body examinations, wound cleansing and dressing, range of motion checks and other similar procedures. c) Administration of Medications via appropriate route whether orally, rectally, topically or through patient's eyes, ears or nostrils, d). Drawing Blood, Bodily Fluids or Tissue Samples such as done for laboratory testing and analysis.

If Patient has any questions or concerns regarding these Medical Dental/ Behavioral Health Treatment/Services, Patient will ask Patient's healthcare provider to provide Patient with additional information. Patient also understands that Patient's healthcare provider may ask Patient to sign additional informed consent documents concerning these or other Medical Dental/ Behavioral Health Treatment/Services.

4. Healthcare Practitioners in Training

Patient recognizes that among those who may attend PCHS there may be medical, nursing and other healthcare personnel who are in training and who, unless specifically requested otherwise, may be present and participate in patient care activities as part of their medical education. Consent is hereby given for the presence and participation of such persons as deemed appropriate by the healthcare provider.

5. Remaining in Patient Care Area and Camera Monitoring/Videotaping/Photography

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CONDITIONS OF SERVICE AND CONSENT FOR TREATMENT

Patient acknowledges and understands that Patient is advised to remain in the patient care area at all times to optimize Patient's medical care and safety. If Patient chooses to leave the area for reasons that are not treatment related, Patient assumes any and all liability for any incident, accident, misadventure or harm, including deterioration of Patient's condition, which Patient may suffer. Patient agrees to hold PCHS and all Healthcare Professionals harmless for any injury or harm resulting from Patient's decision to leave the patient care area and Patient accepts any and all responsibility for such actions. Patient also understands that camera monitoring, videotaping and photography of patient care may be used for clinical purposes and/or safety related purposes.

6. Authorization to Release Information

PCHS is authorized to release information contained in the patient record. The information authorized to be released shall include, but is not limited to, infectious or contagious disease information, including HIV or AIDS-related evaluations, diagnosis or treatment; information about drug or alcohol abuse or treatment of same and/or psychiatric or psychological information. Patient waives any privilege pertaining to such confidential information. PCHS, its agents and employees are hereby released from any and all liabilities, responsibilities, damages, claims and expenses arising from the release of information as authorized above. Reasons for releasing a Patient's record include, but are not limited to, insurance companies, their agents or other third party payors and/or government or social service agencies which may or will pay for any part of the medical/hospital expenses incurred or authorized by representatives of PCHS, as mandated by law, or to alternate care providers, including community agencies and services, as ordered by Patient's healthcare provider or as requested by Patient or Patient's family. PATIENT ACKNOWLEDGES AND AGREES THAT PATIENT'S RECORDS WILL BE AVAILABLE TO ALL PCHS AFFILIATED ENTITIES AND PROVIDERS, AND TO NON-PCHS AFFILIATED REFERRING PROVIDERS IN COMPLIANCE WITH THE PROVISIONS OF MEANINGFUL USE. Patient also agrees, in order for PCHS to service accounts or to collect liabilities owed, to receive contact by telephone at any telephone number associated with their record, including wireless telephone numbers, which could result in charges to Patient. PCHS or its agents may also contact Patient by sending text messages or emails, using any email address Patient provides. Methods of contact may include using pre-recorded/artificial voice messages and/or the use of an automatic dialing service, as applicable.

7. Patient Survey

Patient authorizes PCHS and/or its authorized representative to contact Patient after discharge for the purpose of conducting patient satisfaction surveys and other studies.

8. Patient Rights and Personal Valuables

Patient acknowledges that Patient has received a copy of Patient Rights and has verified the information utilized during this registration and confirms its accuracy. PCHS shall not be liable for the loss or damage of any personal belongings.

9. Consent Timeframe and Applicability

For all PCHS location treatment and services the above consents will be valid for a term of one (1) year from the date of signature below.

Validity of FormPatient acknowledges that a copy or an electronic version of this document may be used in place of and is as valid as the original. Patient understands that the Healthcare Professionals participating in the Patient's care will rely on Patient's documented medical history, as well as other information obtained from Patient, Patient's family or others having knowledge about Patient, in determining whether to perform or recommend the Procedures; therefore, Patient agrees to provide accurate and complete information about Patient's medical history and conditions.

Patient confirms that Patient has read and understood and accepted the terms of this document and the undersigned is the Patient, the Patient's legal representative or is duly authorized by the Patient as the Patient's general agent to execute the above and accept its terms.

____________________________________ _______________________ ____________ ____________Patient/Patient Representative Signature Patient Name (PRINT) Date Time

____________________________________ ___________________________ ____________ __________Relationship to Patient Reasons Patient Unable to Sign Date Time

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Adult Patient History Form

Patient Name: DOB:

Healthcare Provider: Date:

Dentist: Phone Number:

Eye Doctor: Phone Number:

PRESCRIPTION MEDICATIONSPrescription Medication Dose How often taken

NON-PRESCRIPTION (“Over-the-counter” medications such as aspirin, ibuprofen, vitamins, etc.)Non-Prescription Medication Dose How often taken

Herbal Preparation Dose How often taken

ALLERGIES OR DRUG REACTIONS Please list drug and type of reactionAllergy / Drug Name Reaction

PAST MEDICAL HISTORY Please check all that apply.Abnormal heart rhythm Anxiety Gout

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Atrial fibrillation or flutter Arthritis HeadachesHeart attack Asthma HepatitisStroke or TIA Blood disorder Kidney diseaseCongestive heart failure Cancer Kidney stonesHeart valve disease Cataracts Liver diseaseHeart murmur Chronic Lung Disease

(COPD)Prostate problems

High cholesterol Convulsions (seizures) Rheumatic feverClotting disorders Depression Sleep apneaAneurysm Diabetes (insulin dependent) TB or positive skin testHigh blood pressure Diabetes (no insulin) Thyroid diseaseAcid reflux/heartburn Gallstones UlcersAIDS or HIV Gastrointestinal Disease Mental illness

Other:

Preventative Screenings Last Date Completed ResultMammogramPAP TestColonoscopyProstrate ScreeningBone Density TestOther:

PAST SURGICAL HISTORYCoronary bypass Hip replacement TonsillectomyBreast surgery Knee replacement Pacemaker or DefibrillatorGallbladder removal Other orthopedic surgery HysterectomyHernia repair Cardiac Cath SpleenectomyGastric bypass Cardiac Stent

Other:

HOSPITALIZATIONS:

Date: Reason

Date: Reason

Date: Reason

FAMILY HISTORY If condition marked with (S), please specify typeFamily member Father Mother Sibling(s) Father’s

FatherFather’s Mother

Mother’s Father

Mother’s Mother

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Alive/Deceased/Unknown A D U A D U A D U A D U A D U A D U A D UAutoimmune disorder (S)Blood clotting disorder (S)SeizuresCOPDAsthmaHeart diseaseHeart attackHeart bypassHigh blood pressureCongestive heart failureHeart rhythm problemsHigh cholesterolCancer (S)Diabetes (S)Stroke (S)Thyroid disorders (S)Mental illness (S)Addiction (S)Colon cancer (S)Genetic disorders (S)Other (S)

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Social HistoryAlcohol use in past 12 months: Yes No

If yes:

How often? Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week

How many? 1 or 2 3 or 4 5 or 6 7 - 9 10+

How often 6 or more on one occasion?

Never Less than monthly Monthly Weekly Daily or almost daily

Caffeine: Yes No Amount: Frequency:Have you ever used drugs other than for medical reasons? Yes No

Education? High School Diploma GED Associates Bachelors Other

Exercise Yes No Frequency:

Carbon Monoxide detector in house: Yes No

What is your primary language?

Legal problems: Yes No

Marital Status: Single Married Partner Separated Divorced Widowed

Employment:

Smoke detector in house: Yes No

Tobacco Use: Current Former: Year Quit Never E-cigarettes/Vaping

If Current Smoker:

How often? Every Day Some Days

How many per day? 5 or less 6-10 11-20 21-30 31+

How soon after waking up? Within 5 minutes 6-30 min 31-60 min 60+ min

Interested in quitting?

Ready to quit Thinking about quitting Not ready to quit

Second hand smoke exposure? Yes No How often:

Travel outside US within past: 2 weeks 3 months 1 year none

Do you feel safe at home? Yes No Location:

Do you use chewing tobacco? Yes No

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Patient Bill of Rights & Responsibilities

Our patients have the right to…

1. receive service without regard to age, race, color, sexual orientation, religion, marital status, gender, national origin or sponsor;

2. be treated with consideration, respect and dignity including privacy in treatment;

3. be informed of the services available and the name and function of person providing health care services;

4. receive from your health care provider information necessary to give informed consent prior to the start of any non-emergency procedure or treatment or both. An informed consent shall include, at a minimum: information concerning the procedure or

treatment or both; the reasonably foreseeable risks; alternatives for care or treatment, if any, as a

reasonable provider under similar circumstances would disclose;

5. be informed of off-hour emergency coverage;

6. be informed of the charges for services, assistance in determining eligibility for third-party reimbursements and, when applicable, informed of the availability of discounted cost care;

7. receive an itemized copy of your bill upon request;

8. obtain from your health care provider, or their delegate, complete and current information concerning your diagnosis, treatment and prognosis in terms you can be reasonably expected to understand;

9. obtain from your health care provider, or their

delegate, complete and current information concerning your diagnosis, treatment and prognosis in terms you can be reasonably expected to understand;

10. voice grievances and recommend changes in policies and services to PCHS staff, administration, and the Alaska State Department of Health without fear of reprisal;

11. express complaints about the care and services provided and to have such complaints investigated. PCHS is responsible for providing a written response within 30 days, if requested, indicating the findings of the investigation. PCHS is also responsible for notifying you or your designee that if you are not satisfied with the response, you may register a complaint to the Alaska State Department of Health & Human Services Office, by phone (907)465-4722 or at www.hss.state.ak.us;

12. appoint someone you trust to decide about your treatment, if you lose the ability to decide for yourself;

13. receive care in an environment where pain and/or suffering can be expressed with comfort and dignity;

14. access or amend your health record as allowed by privacy laws;

15. privacy and confidentiality of all information and records pertaining to your treatment; and

16. approve or refuse the release or disclosure of contents of your health record except as required or allowed by law.

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Patient Bill of Rights & Responsibilities

The patient or their legally designated representative is responsible…

1. to actively participate in their care to the fullest extent possible;

2. to provide, to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to their health;

3. to make it known whether they clearly understand a suggested course of action and what is expected of them;

4. to follow the treatment plan recommended by the health care provider. This may include following the instructions of health care personnel as they carry out the coordinated plan of care and implement the health care providers orders;

5. to report unexpected changes in their condition to their provider;

6. to keep appointments and, when unable to do so for any reason, to follow the terms of the appointment policy;

7. for their actions if they refuse treatment or do not follow provider instructions. If the patient cannot follow through with the treatment, they are responsible for informing the health care provider;

8. for assuring that the financial obligations of their health care are fulfilled as promptly as possible. You are responsible for providing information needed by PCHS to secure payment;

9. for following clinic rules and regulations affecting patient care and conduct;

10. for being considerate of the rights of other patients and personnel;

11. for being respectful of the property of PCHS and others;

12. for recognizing the effect of lifestyle on your health which depends not just on the care you receive but on the decisions you make in your daily life; and

13. for assuring that children brought into a PCHS facility by you are supervised at all times.

PCHS Contact Numbers:PCHS Medical – Soldotna(907) 262-3119

PCHS Medical – Kenai(907) 283-3600

PCHS Dental (907) 283-7759

PCHS Behavioral Health–Soldotna (907) 260-3691

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Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED ANDHOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY._______________________________________________________________Your medical information is Protected Health Information (PHI) about you, including demographic information, that may identify you and that relates to your past, present and future physical, dental or behavioral health and related health care activities. We understand that your PHI is personal. We are committed to protecting your PHI and to sharing the minimum necessary information required to accomplish each purpose or disclosure. We create a record of the care and services you receive through Peninsula Community Health Services (PCHS). This notice applies to all your PHI that we have collected while caring for you at our agency.

This Notice of Privacy Practices describes how we are allowed to use and disclose your PHI to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law (see in the body of the Notice). The Notice also describes your right to access and control your PHI.

I. USES AND DISCLOSURES OF PHI WITHOUT YOUR AUTHORIZATION We use and disclose your PHI for treatment, payment, and healthcare operations. This privacy notice about PHI includes your dental, behavioral health and physical health services information collected by the staff and providers of PCHS.

A. Treatment: We may use or disclose your dental, behavioral and physical PHI to provide, coordinate or manage your healthcare services at PCHS. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

B. Payment: We may use and disclose your dental, behavioral health and physical PHI to obtain payment for services we provide to you. Information that may be shared includes, but is not limited to: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and utilization review activities. For example if you have health insurance and we bill your insurance directly, we will include information that identifies you, as well as your diagnosis, the procedures performed, and supplies used so that we can be paid for the treatment provided.

C. Healthcare Operations: We may use and disclose your dental, behavioral health and physical health information for our healthcare operations to support the business activities of PCHS. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities, and conducting or arranging for other business activities.

1. We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract, Business Associate and Qualified Service Organization Agreement, which contains terms that will protect the privacy of your protected health information.

2. We may use basic demographic information limited to your name, date of birth, address, phone number, health insurance status, and the dates you received services, department of service information, treating provider information, and outcome information to contact you for fundraising activities. We will not prohibit or condition treatment of payment on whether you choose to receive fundraising communications. We raise funds to expand and support healthcare services, education programs, etc. We will not sell, trade, or loan your information to any third parties. You have the right to request not to receive this information. If you do not want to receive these materials, please contact our Compliance Officer and request that these fundraising materials not be sent to you.

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3. We may contact you to remind you about appointments, test results, inform you about treatment options or advise you about other health-related benefits.

D. Other Use and DisclosuresWe also use and disclose your information to enhance healthcare services, protect patient safety, safeguard public health, ensure that our facilities and staff comply with government and accreditation standards, and when otherwise allowed by law. For example we provide or disclose information:

1. Abuse, Neglect or Domestic Violence: We may disclose your PHI to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. We will make this disclosure only when specifically required or authorized by law or when you agree to the disclosure.

2. Health Oversight Activities: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, civil, administrative or criminal investigations, proceedings or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law. We will not disclose your PHI if you are the subject of an investigation and your PHI is not directly related to your receipt of health care or public benefits. In accordance with 7 ACC 71.400 – 7 ACC 71.449, we will disclose PHI to the Division of Mental Health & Developmental Disabilities (DMHDD) for health oversight activities specifically identified in Alaska law.

3. In Connection with Judicial and Administrative Procedures: We may disclose your PHI in the course of any judicial or administrative proceedings in response to an order of a court or magistrate as expressly authorized by such order or in response to a signed authorization.

4. Law Enforcement Purposes: We may disclose PHI to a law enforcement official as required by law.

5. Coroners, Medical Examiners, and Funeral Directors: We may disclose PHI to a Coroner or Medical Examiner or Funeral Director as authorized by law.

6. Imminent Threat to Health or Safety: Consistent with applicable federal and state laws, we may disclose your PHI if we believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

7. To a Designated Hospital In the Event of an Involuntary Commitment: We may disclose your protected dental, medical and behavioral health PHI to assure continuity of care.

8. Specialized Government Functions: We may disclose to military authorities the PHI of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials PHI required for lawful intelligence, counterintelligence, and other national security activities. We may disclose PHI to a correctional institution or law enforcement official having lawful custody of inmate or patient under certain circumstances.

9. Natural Disaster: We may use or disclose your location and general condition to an authorized public or private entity (such as FEMA or the Red Cross) authorized by its charter or by law to assist in disaster relief efforts.

10. For Research Purposes: We may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.

II. Other Uses and Disclosures When You Have an Opportunity to Object

A. To Your Family or Friends: Unless you object, your healthcare provider will use his or her professional judgment to provide relevant protected health information to your family member, friend, or another person. This person

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would be someone that you indicate has an active interest in your care or the payment for your healthcare or who may need to notify others about our location, general condition, or death.

B. Others Involved In Your Healthcare: We may use or disclose PHI to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative, or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your PHI, we will provide you with an opportunity to object to the use or disclosure.

C. Natural Disaster: We may use or disclose your location and general condition to an authorized public or private entity (such as FEMA or the Red Cross) authorized by its charter or by law to assist in disaster relief efforts.

D. In a Medical or Psychological Emergency: If you are incapacitated or in an emergency, we will disclose PHI using our professional judgment, only PHI that is directly relevant to the person’s involvement in your healthcare. If this is a behavioral health concern, the contact will occur if you are a danger to yourself or others, or you are unable to meet your basic needs. We will also use our professional judgment and experience with common practice to make reasonable accommodation in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of PHI.

E. Deceased Individuals: We may disclose to a family member, or other persons who were involved in an individual’s care prior to the individual’s death, PHI of the individual that is relevant to such a person’s involvement, unless doing so is inconsistent with any prior expressed preference of the individual that is known to PCHS.

III. Substance and Alcohol Abuse Diagnosis or Treatment

A. Substance Abuse Diagnosis or Treatment. If you have applied for or been given a diagnosis or treatment for alcohol or drug abuse, or a dual diagnosis involving alcohol or drug abuse, then there may be additional confidentiality protections applicable to your PHI under the federal regulations at 42 CFR Part 2.

IV. Use and Disclosure Requiring Your Authorization

A. Other then the uses and disclosures described above, we will not use or disclose your protected health information without your written authorization. PCHS requires your written authorization for most uses of psychotherapy notes, for marketing (other than face to face communication between you and a PCHS staff member, a promotional gift of nominal value); or before we sell your protected health information. For all other disclosures of your PHI we must obtain a written authorization for release of information from you. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Other uses and disclosures not described in this notice will be made only with your authorization.

V. Your Rights Regarding Protected Health Information

A. Access: You have the right to look at or get copies of your PHI, with limited exceptions. If we determine that providing you access to your record constitutes a danger to you or others, we can use our professional judgment regarding that access. You may request that we provide copies in a format other than photocopies. We will use the format you request if reasonably possible. You must make a request in writing to obtain access to your PHI. You may obtain a form to request access by using the contact information listed at the end of this Notice. We may charge you a reasonable cost-based fee for expenses such as copies and staff time.

B. Disclosure Accounting: You have the right to request a list of instances where we or our business associates, disclosed your PHI for reasons other than treatment, payment, healthcare operations and certain other activities. Your first accounting of disclosures is free of charge. Any additional request within the same calendar year requires a processing fee.

C. Restriction: You have the right to request in writing restrictions on our use or disclosure of your PHI for treatment, payment or healthcare operations. We are not required to agree to additional restrictions but if we do agree, we must abide by those restrictions, except in an emergency situation or as required by law. If you make your request to the PCHS Compliance Office, we will provide you with a written notice of our decision about your request.

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D. Restriction on Certain Disclosures to Health Plans: You have a right to request a restriction on disclosures to a health plan for a health care item or service for which you, or a person other than the health plan on your behalf, has paid PCHS in full. PCHS must agree to this request, unless a law requires us to share that information.

E. Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or at an alternative location. Your request must be in writing and specify the alternative means or location. Your request must specify how and where you wish to be contacted. We will accommodate reasonable requests.

F. Amendment: You have the right to request that we amend your PHI. Your request must be made to your provider, in writing, and it must explain why the information should be amended. We may deny your request and we will do so in writing. You have the right to file a statement of disagreement with us and we may prepare a response to your statement and will provide you with a copy of any response. It will be added to your medical record.

G. Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive a paper copy of this Notice.

VI. Our Legal DutiesWe are required by law to maintain the privacy of your protected health information, notify affected individuals following a breach of unsecured protected health information, provide this notice about our privacy practices, and follow the privacy practices that are described in this Notice.

VII. QUESTIONS AND COMPLAINTS For more information about our privacy practices or if you have questions or concerns, please contact us. If you feel that we have violated your privacy rights you may complain to us using the contact information listed below. You may also submit a written complaint to the U.S. Department of Health and Human Services. You may also contact the Office of Civil Rights to file a complaint. We will provide you with their address upon request.

We support your right to the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. You may contact our Compliance Officer at:

Compliance OfficerPeninsula Community Health Services230 E. Marydale Ave, Suite 3Soldotna, Alaska, 99669Phone: (907) 260-7338

VIII. Reservation of Right to Change this NoticeWe reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for PHI we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office. The notice will include on the bottom of every page the effective date. You will be offered a copy of the current notice when you visit our offices for services.

IX. Effective Date of this Notice of Privacy Practices This Notice of Privacy Practices is effective 9/11/2013

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