Klamath Health Partnership

OTHER USES AND DISCLOSURES OF HEALTH INFORMATIONWe will not use or disclose your health information for any purpose other than those identified in theprevious sections without your specific, written Authorization. If you give us Authorization to use ordisclose health information about you, you may revoke that Authorization, in writing, at any time. If yourevoke your Authorization, we will no longer use or disclose information about you for the reasonscovered by your written Authorization, but we cannot take back any uses or disclosures already madewith your permission.In some instances, we may need specific, written authorization from you in order to disclose certain typesof specially-protected information such as HIV, substance abuse, mental health, and genetic testinginformation.YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOUYou have the following rights regarding health information we maintain about you: Right to Inspect and Copy. You have the right to inspect and copy your health information,such as medical and billing records, that we keep and use to make decisions about your care.You must submit a written request to our Privacy Officer (Kacie Whitehead) in order to inspectand/or copy records of your health information. If you request a copy of the information, we maycharge a fee for the costs of copying, mailing or other associated supplies.We may deny your request to inspect and/or copy records in certain limited circumstances. If youare denied copies of or access to health information that we keep about you, you may ask thatour denial be reviewed. If the law gives you a right to have our denial reviewed, we will select alicensed health care professional to review your request and our denial. The person conductingthe review will not be the person who denied your request, and we will comply with the outcomeof the review. Right to Amend. If you believe health information we have about you is incorrect or incomplete,you may ask us to amend the information. You have the right to request an amendment as longas the information is kept by this office.To request an amendment, complete and submit a MEDICAL RECORDAMENDMENT/CORRECTION FORM to our Privacy Officer.We may deny your request for an amendment if your request is not in writing or does not includea reason to support the request. In addition, we may deny your request if you ask us to amendinformation that: Page 4 We did not create, unless the person or entity that created the information is no longeravailable to make the amendment Is not part of the health information that we keep You would not be permitted to inspect and copy Is accurate and completeRight to an Accounting of Disclosures. You have the right to request an “accounting ofdisclosures.” This is a list of the disclosures we made of medical information about you forpurposes other than treatment, payment, health care operations, and a limited number of specialcircumstances involving national security, correctional institutions and law enforcement. The listwill also exclude any disclosures we have made based on your written authorization.Form ENotice of Privacy Practices Oregon Medical Association10/2002

To obtain this list, you must submit your request in writing to our Privacy Officer. It must state atime period, which may not be longer than six years and may not include dates before April 14,2003. Your request should indicate in what form you want the list (for example, on paper,electronically). The first list you request within a 12-month period will be free. For additional lists,we may charge you for the costs of providing the list. We will notify you of the cost involved andyou may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on thehealth information we use or disclose about you for treatment, payment or health care operations.You also have the right to request a limit on the health information we disclose about you tosomeone who is involved in your care or the payment for it, like a family member or friend. Forexample, you could ask that we not use or disclose information about a surgery you had.We are not required to agree to your request. If we do agree, we will comply with your requestunless the information is needed to provide you emergency treatment or we are required by lawto use or disclose the information. To request restrictions, you may complete and submit the REQUEST FOR RESTRICTION ONUSE/DISCLOSURE OF MEDICAL INFORMATION to our Privacy Officer.Right to Request Confidential Communications. You have the right to request that wecommunicate with you about medical matters in a certain way or at a certain location. Forexample, you can ask that we only contact you at work or by mail.To request confidential communications, you may complete and submit the REQUEST FORRESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR CONFIDENTIALCOMMUNICATION to our Privacy Officer. We will not ask you the reason for your request. Wewill accommodate all reasonable requests. Your request must specify how or where you wish tobe contacted. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. Youmay ask us to give you a copy of this notice at any time. Even if you have agreed to receive itelectronically, you are still entitled to a paper copy.To obtain such a copy, contact our Privacy Officer, Kacie Whitehead.CHANGES TO THIS NOTICEWe reserve the right to change this notice, and to make the revised or changed notice effective formedical information we already have about you as well as any information we receive in the future. Wewill post the current notice or a summary of the current notice in the office with its effective date in the topright hand corner. You are entitled to a copy of the notice currently in effect.COMPLAINTSIf you believe your privacy rights have been violated, you may file a complaint with our office or with theSecretary of the Department of Health and Human Services. To file a complaint with our office, contactKacie Whitehead, Privacy Officer at (541) 851-8110. You will not be penalized for filing a complaint.10/2002Notice of Privacy Practices Oregon Medical AssociationForm EPage 5

Klamath Health Partnership, Inc.Notice about Nondiscrimination andAccessibility RequirementsDiscrimination is Against the LawKlamath Health Partnership, Inc. complies with applicable Federal civil rights laws and does not discriminateon the basis of race, color, national origin, age, disability, or sex Klamath Health Partnership, Inc. does notexclude people or treat them differently because of race, color, national origin, age, disability, or sex.Klamath Health Partnership, Inc.: Provides free aids and services to people with disabilities to communicate effectively with us, such as:o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, otherformats) Provides free language services to people whose primary language is not English, such as:o Qualified interpreterso Information written in other languagesIf you need these services, contact Klamath Health Partnership, Inc. at 541-851-8110, daily from 7:00 AM to6:00 PM.If you believe that Klamath Health Partnership, Inc. has failed to provide these services or discriminated inanother way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:Evelyn Lowell, Compliance Officer2074 S. 6th StreetKlamath Falls, OR 976011-877-672-8620hr@kodfp.orgYou can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, contactCustomer Service at 541-851-8110, daily from 8:00 AM to 6:00 PM.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office forCivil Rights, electronically through the Office for Civil Rights Complaint Portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Klamath Health Partnership, Inc.Language AccessEspañol (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.Llame al 1-541-851-8110Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọisố 1-541-851-8110繁體中文 (Chinese) �費獲得語言援助服務。請致電 1-541-851-8110Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услугиперевода. Звоните 1-541-851-8110한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-541851-8110 번으로 전화해 주십시오.УКРАЇНСЬКА (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися добезкоштовної служби мовної підтримки. Телефонуйте за номером 1-xxx-xxx-xxxx日本語 (Japanese) ��1-541-851-8110 51-541-1 اتصل برقم . فإن خدمات المساعدة اللغوية تتوافر لك بالمجان ، إذا كنت تتحدث اذكر اللغة : ملحوظة ARABIC / اللغة العربية .8110ລາວ (Lao) ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເວ້ າພາສາ ລາວ, ການບໍລິການຊ່ ວຍເຫຼື ອດ້ ານພາສາ, ໂດຍບໍ່ເສັຽຄ່ າ, ແມ່ ນມີພ້ ອມໃຫ້ ທ່ານ. ໂທຣ 1541-851-8110.ไทย (Thai) เรียน: ถ �ณสามารถใช �างภาษาได ้ฟรี โทร 1-541-851-8110Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposésgratuitement. Appelez le 1-541-851-8110.Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungenzur Verfügung. Rufnummer: 1-541-851-8110.Română (Romanian) ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică,gratuit. Sunați la 1-541-851-8110.Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaanala, ni argama. Bilbilaa 1-541-851-8110Kajin Majel (Marshallese) LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃejjeḷọk wōṇāān. Kaalọk 1-541-851-8110ភាសាខ្មែ រ (Cambodian) ប្រយ័ត្ន៖ បរើសិនជាអ្ន កនិយាយ ភាសាខ្មែ រ, បសវាជំនួយខ្នន កភាសា បោយមិនគិត្ឈ្ន �ំប រ ើអ្ន ក។ ចូ រ ទូ រស័ព្ទ 1-541-851-8110(Burmese) သတိျ ပဳရန္ - အကယ္၍ သင္သ ည္ ျ မန္မာစကာား ကိို ေျျ ပာပါက၊ ဘာသာစကာား အကူအညီ၊ အခမဲ့၊ သင္္ျ �� ဖိုန္ျားနံပါတ္ 1-541-851-8110 သိုျ႔ိ ေျခၚဆိိုပါ။

Klamath Health Partnership, Inc.ACKNOWLEDGMENT AND CONSENTI understand that Klamath Health Partnershipand disclose health information about me.Inc. (Referred to below as “This Practice”) will useI understand that my health information may include information both created and received by the practice,may be in the form of written or electronic records or spoken words, and may include information about myhealth history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures,prescriptions, and similar types of health-related information.I understand and agree that This Practice may use and disclose my health information in order to; Make decisions about and plan for my care and treatment;Refer to, consult with, coordinate among, and manage along with other health care providers for mycare and treatment;Determine my eligibility for health plan or insurance coverage, and submit bills, claims and otherrelated information to insurance companies or others who may be responsible to pay for some or all ofmy health care; andPerform various offices, administrative and business functions that support my physician’s efforts toprovide me with, arrange and be reimbursed for quality, cost-effective health care.I also understand that I have the right to receive and review a written description of how This Practice willhandle health information about me. This written description is known as a Notice of Privacy Practices anddescribes the uses and disclosures of health information made and the information practices followed by theemployees, staff and other office personnel of This Practice, and my rights regarding my health information.I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled toreceive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of themost current version of This Practice’s Notice of Privacy Practices in effect will be posted inwaiting/reception area and on our website at: www.klamathopendoor.comI understand that I have the right to ask that some or all of my health information not be used or disclosed inthe manner described in the Notice of Privacy Practices, and I understand that This Practice is not required bylaw to agree to such requests.By signing below, I agree that I have reviewed and understand the information above and that I havereceived a copy of the Notice of Privacy Practices.By:(Patient)Date:-ORBy:(Patient representative)Date:Description of Representative’s Authority:10/2002Acknowledgment and Consent Oregon Medical AssociationForm A

PATIENT AGREEMENT FORMPlease initial in each boxCO-PAYMENTS AND DEDUCTIBLES ARE DUE AT TIME OF SERVICE: We will collectyour co-payment or sliding fee arrangement at the time of each appointment. Also,payment must be made in advance for any elective services that are not covered byyour insurance, or if the deductible has not been met, before the procedure will bescheduled. It is necessary to speak with the billing office to establish payments.MEDICATIONS: Please bring a list of your medications and vitamins or the bottles ofall medications and vitamins that you are currently taking to the first appointmentwith your provider.PLEASE NOTE: Some medications are under the surveillance of the DrugEnforcement Agency, including opiate pain medications (such as Vicodin,Oxycodone, Methadone) and benzodiazepines (Ativan,Valium,Xanax, and Klonopin).By clinic policy, our providers will not refill these medications at your first visit withour clinic. If you are on a medication such as this on a continuous basis, pleaseobtain a refill from your prior medical provider to cover you until your secondappointment at our clinic.PRESCRIPTION REFILLS: Call your pharmacy for all prescription refills and thepharmacy will contact our office for a refill. Even if there are no refills left, thepharmacy will contact our office for authorization. Those prescriptions requiring ahard copy to be hand carried to the pharmacy can be picked up at the clinic. Ourclinic policy is that providers must review and confirm medical records prior toprescribing medications to the patient.CHECK-IN TIME: You are expected to check in 15 minutes prior to your scheduledappointment time.Late Arrival: If you are more than 10 minutes late to your appointment, theappointment may need to be rescheduled. This is to ensure that the patients thatarrive on time do not wait longer than necessary to see the provider. You may begiven the option to wait for another appointment time on the same day if one isavailable. We will try to accommodate late-comers as best as possible, but cannotcompromise on the quality and timely care provided to our other patients.

CANCELLED APPOINTMENTS: We require a 24-hour notice when cancelling yourappointment.FAILED APPOINTMENTS: A late cancellation is considered a failed appointment.NEW PATIENTS: New Patients that fail to attend 2 New Patient appointmentswithout cancelling 24 hours in advance will no longer have the opportunity toschedule further appointments at Klamath Health Partnership, Inc. clinics.ESTABLISHED PATIENTS: Established patients that fail to attend 3 appointmentswithout cancelling 24 hours in advance within a 12 month period will be dismissedfrom the practice and no longer able to schedule appointments at Klamath HealthPartnership, Inc. clinics.INSURANCE BILLING: Please provide us with complete and accurate insuranceinformation at every appointment, as well as any changes in your address, telephonenumber and employer. We accept all commercial insurances, Medicare andMedicare Advantage plans, and Oregon Health Plan managed care plans includingCascade Comprehensive Care. We do not accept any Medicaid insurance programsthrough other states or counties.NON-INSURED: Our clinic offers a sliding scale fee based on your annual income todiscount the charges for our services. X-rays will not slide.SLIDING SCALE FEE: All of our patients can apply for this program even those withinsurance coverage. You are required to fill out and sign the income verification formand return to the registration desk with acceptable proof of income to qualify for thisprogram. The scale which you qualify at depends upon your annual income. You arerequired to re-apply for the sliding scale annually or whenever your income changes.LABS: The majority of lab specimens collected in our lab are sent out to InterPathLaboratory to run the tests. InterPath bills separately for its services and uses aseparate sliding scale for their charges. If you have any questions about your lab billplease contact InterPath directly.REMINDER CALLS: With my consent, KHP may call my home or other designatedlocation and leave a message reminding me of my appointments. Please provide theappropriate contact numbers and PLEASE let us know if you DO NOT want to becontacted.PBM Consent: Prescription Benefit Manager allows prescribers to obtain criticalpatient drug information during the time of the office visit.

Klamath Health Partnership Inc.PATIENT REGISTRATION FORMDate:PATIENT INFORMATION:Patient is a minorPatient will be paying cash for servicesPatient is the Primary Insurance Policy HolderPatient is the Person Responsible for this accountName: Middle Initial: Last Name:Address: City, State, Zip code:Home Phone: Work Phone: Cell Phone:Date of Birth:Patient Age:Patient SSN:Pharmacy of Choice:GUARANTOR ACCOUNT/ RESPONSIBLE PARTY INFORMATION (Do Not State Insurance):Person Responsible is the Primary Policy HolderPerson Responsible is the Secondary Policy HolderPatient is the Person Responsible for this accountPerson Responsible will be paying cash for servicesLegal Name:Address: City, State, Zip code:Home Phone: Work Phone: Cell Phone:Responsible Party’s Date of Birth: Responsible Party SSN:EMERGE

KLAMATH OPEN DOOR FAMILY PRACTICE 2074 S. 6th Street Klamath Falls, OR 97601 Phone: 541-851-8110 Fax: 541-851-8114 Hours Mon-Fri: 7am - 6pm Saturday: 8am - noon Sunday: CLOSED CHILOQUIN OPEN DOOR FAMILY PRACTICE 103 S. Wasco Avenue Chiloquin, OR 97624 Phone: 541-783-2292 Fax: 541-783-3160 Hours: M, T, W, F: 8am - 6pm Thursday: 8am - 5pm