2023 Patient Registration (English)

HIPAA Authorization Form

Bartz-Altadonna Community Health Center
Bartz Altadonna Community Health Center (BACHC) has taken measures to protect all of our patients' private medical information.BACHC will not release any information to anyone unless you have provided the requested information below. These would be
people other than what is covered in our Notice of Privacy Practices.

Your protected health information will be used by BACHC or disclosed to others for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice. Please review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice and request a copy of the Notice of Privacy Practices for your own records. See the Client Services Representative to receive a copy.

You may request a restriction on the use or disclosure of your protected health information. BACHC may or may not agree to restrict the use or disclosure of your protected health information. If BACHC agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed-upon restriction will be a violation of the Federal Privacy Standards.

You may revoke this consent to the use and disclosure of your protected health information. You must revoke consent in writing.Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

Please see the Client Services Representative with any questions prior to signing this authorization form.
PERSONS AUTHORIZED TO OBTAIN MEDICAL INFORMATION
Patient Name:   First Name   Last Name
If under 18 years of age, or has a guardian. Name of guardian :   First Name   Last Name

I   First Name   Last Name   give permission to Barta-Altadonna Community Health Center to disclose health and/or billing information to the individuals identified below that are involved in patient care or payment of care. I understand BACHC is not responsible for the information provided as long as it is given to a person that I have listed below.

Date of Birth must be provided so that our office can verify that we are speaking to the correct person.
Name of Person #1 Authorized to Obtain Medical Information

First NameLast NameRelationship
Date of Birth

MonthDayYear
Date
Primary Phone Number
Please enter a valid phone number.
Name of Person #2 Authorized to Obtain Medical Information

First NameLast NameRelationship
Date of Birth

MonthDayYear
Date
Primary Phone Number
Please enter a valid phone number.
Relationship to Patient*
If self input "Self"
Signature*

Clear

Consents and Acknowledgements

Bartz-Altadonna Community Health Center
In order for you to become a patient, we need your consent to provide you with care. We also need you to acknowledge that we have provided you with certain important information and documents. If you have any questions about any of this information or need help completing this form, please do not hesitate to ask a member of our staff. It is important to us that you feel comfortable with all of this information. By signing, you are indicating that you understand the information, have been given a chance to ask questions, and are giving your consent.

GENERAL CONSENT TO TREAT
I voluntarily agree to receive services from BACHC and authorize the providers of BACHC to provide such care, treatment, or services as are considered necessary and advisable for me. I understand that I should participate in the planning for my care and that I have a right to refuse interventions, treatment, care, services, or medications at any time to the extent the law allows. I know that the care I will receive may include tests, injections, and other medications, etc., that are based on established medical criteria, but not free of risk. Finally, I know that BACHC sometimes has students/residents being trained as doctors, nurses, therapists, and other health care providers who might be helping to care for me. These students are under the supervision of licensed providers.

I understand that BACHC is committed to involving me in my care and that no one can be given care atBACHC without agreeing to the care unless there is an emergency. If there is an emergency, I know that someone at BACHC may help me without waiting for me to say okay. I understand that some services require me to sign another Informed Consent to Treatment, so I may be asked to complete that later.

NOTICE OF PRIVACY PRACTICE
I have been given a copy of BACHC’s Notice of Privacy Practices and I understand that BACHC is required by law to protect my personal health information. I have had the chance to ask questions about BACHC’s Notice of Privacy Practices and feel comfortable with the protections that it offers me. I understand that there are times when the law allows my personal health information to be shared with individuals or entities outside of BACHC, including but not limited to for treatment, payment, and operations purposes, when required by law, and in connection with the mandatory reporting of certain diseases.

INTEGRATED MODEL OF CARE
BACHC offers a wide variety of services to its clients. I understand that in order for me to get the best service for my needs, programs within BACHC may share information concerning my health to ensure the quality and continuity of my care across service areas.

HEALTH INFORMATION EXCHANGE
I understand thatBACHCparticipatesin certain health information exchanges with other hospitals and health centers located in the Antelope Valley and surrounding areas. Your health information may be shared with these exchanges to provide faster access, better coordination of care, and to assist providers and public health officials in making more informed decisions. Please notify BACHC if you wish to “opt-out” and disable access to your health information, except to the extent that disclosure of such information is permitted or mandated by law.

PATIENT RIGHTS AND RESPONSIBILITIES
I have been given a copy of the BACHC Patient Rights and Responsibilities document and understand that both the Rights and the Responsibilities laid out in that document must govern my interactions at BACHC. I also understand that BACHC and I are responsible for adhering to the Rights and Responsibilities. I understand that I have a right to file a complaint or grievance withBACHC, as described inBACHC’s Patient Handbook. The Patient Handbook contains information about being a patient at BACHC, including services that BACHC offers, hours of operation, and contact information for services.

RELEASE OF INFORMATION FOR BILLING AND CONSENT TO REIMBURSE
I know that BACHC needs to send parts of my personal health information to organizations that help pay for my care, such as my insurance company or an organization that grants money to BACHC. I allow BACHC to release the relevant parts of my records so that my care can be paid for. If I do not feel comfortable with this, then I understand that I can request a higher level of privacy protection than is afforded to me under the Health Insurance Portability and Accountability Act(HIPAA).

ACKNOWLEDGMENT OF DUTY TO REIMBURSE BACHC FOR HEALTH CARE SERVICES
I understand that BACHC offers a Sliding Fee Scale of discounted or free health care items and services to individuals who are deemed unable to pay
based on their level of income. In order to be eligible for BACHC’s Sliding Fee Scale of discounted or free services, I will need to provide BACHC’s
Client Services team with documents establishing that I meet income eligibility requirements. If I do not provide the required documents to BACHC, I
am responsible for paying my fees for medical and behavioral health at BACHC in full at the time of service
By signing my name below, I am acknowledging that I have read, and fully understand, each of the separate paragraphs set forth above.
Signature*

Clear

Patient Acknowledgement of Financial Obligation

Bartz-Altadonna Community Health Center
Bartz-Altadonna Community Health Center(“BACHC”)is a Federally Qualified Health Center that is subject to Section 330 of the Public Health Service Act. Section 330 specifies that Health Centers must assure that no patient will be denied services due to theirin ability to pay for such services. It also requires HealthCentersto adopt written policies and procedures to maximize collections and reimbursement for their costs in providing health services.

I UNDERSTAND THAT I AM RESPONSIBLE FOR:
- Contributing to the cost of my care and treatment as my health insurance coverage requires and based on my ability to pay;
- Providing BACHCwith the information it needsto receive reimbursement forthe treatment orservicesit providesto me;
- Requesting consideration for discounted fees underBACHC’s Sliding Fee Scale based on my level of income, and providing documentation to
  support eligibility for discounted fees that may be requested by BACHC’sRegistration and Benefitsteam;
- Assisting the registration and Benefits team with any application forinsurance or public benefitsthat I may be entitled to;
- Paying my co-payment (if applicable) when I check-in for my appointment and paying my deductible or any otherfeesthat may be owed at the
  conclusion of the medical visit;
- Paying my feesfor medical and behavioral health received atBACHC in full at the time ofservice, either upon check-in or at check-out as requested by BACHCif I have been deemed a self-pay patient based on the fact that I have insurance coverage that BACHC does not accept but have elected to remain in care at BACHC.
Signature*

Clear

Authorization to Release Health Information

Bartz-Altadonna Community Health Center
YOU ARE REQUIRED TO READ AND SIGN BELOW. I UNDERSTAND THAT:
- I understand that the health center will not deny me treatment because I refuse to sign this Authorization.
- I understand that I may revoke this Authorization at any time by submitting a written request to BACHC unless the health center has already taken action based on this Authorization, or unless this Authorization is given as a condition of obtaining insurance coverage and the insurer has certain legal rights to contest the policy or a claim under the policy.
- I understand that this Authorization is valid for a one-year period from the date of my signature below, but that the information disclosed based on
  this Authorization may be re-disclosed by the entity or the person who receives the information. Once disclosed, it is possible that the information
  will no longer be protected under Federal or State privacy laws.
- I may inspect or copy the medical information that is being released, used, and/or shared pursuant to this Authorization Form.
- The use or disclosure of information obtained or released pursuant to this Authorization may result in direct or indirect payment to BACHC from
  a third-party, including copying fees.
- I understand that the use or disclosure of HIV-related, drug/alcohol, and mental/behavioral health information and treatment is highly sensitive and
  requires the specific authorization I have provided by marking the boxes above.
- I understand that if the records or information being released involve treatment for alcohol or substance addiction, my records are also protected by
  Federal law and regulations relating to “confidentiality of alcohol or drug abuse patient records,”(42 C.F.R. Part 2, 42 U.S.C. § 290dd-2).
- I understand that there may be a charge for the requested records.
Signature

Clear
Name

First NameLast Name
BACHC understands the importance of your request and strives to process your request as soon as possible in the order in which your request was received. Please let us know if the requested information is needed by a specific date and every effort will be made to meet your needs. BACHC complies with HIPAA regulations which require the processing of requests for medical information within 30 business days of request.

NOTE TO INDIVIDUAL OR ENTITY AUTHORIZED TO RECEIVE ALCOHOL OR SUBSTANCE ABUSE ADDICTION RECORDS Pursuant to This Notice: This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 CFR Part 2) relating to the confidentiality of alcohol and substance abuse records. Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules also restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client of BACHC.

ADVANCE HEALTH CARE DIRECTIVE

Bartz-Altadonna Community Health Center
An Advance Health Care Directive is a legal document that allows you to make decisions about your medical treatment in the event that you are unable to make them yourself. It is a way for you to communicate your wishes to your healthcare providers and loved ones, and ensure that your medical care is aligned with your values and preferences.

The document typically includes instructions for your healthcare providers about the types of medical treatment you want or do not want, and under what circumstances you would like certain treatments to be provided or withheld. It may also include information about your end-of-life care preferences, such as whether you would like to receive life-sustaining treatments, and if so, for how long.

Creating an Advance Health Care Directive is important because it allows you to maintain control over your medical care, even if you are unable to communicate your wishes due to illness or injury. It also provides guidance for your loved ones, who may otherwise be unsure about how to make medical decisions on your behalf.

It is important to discuss your wishes with your healthcare providers and loved ones, and to review and update your Advance Health Care Directive regularly to ensure that it reflects your current values and preferences.
Are you interested in having a advance health care directive?

YesNo (refuse)
Should be Empty:

PATIENT REGISTRATION

PATIENT INFORMATION

CONTACT INFORMATION

PATIENT DEMOGRAPHICS

GUARANTOR (Person to Be Billed)

MEDICAL INSURANCE

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

HIPAA Authorization Form

PERSONS AUTHORIZED TO OBTAIN MEDICAL INFORMATION

Consents and Acknowledgements

Patient Acknowledgement of Financial Obligation

Authorization to Release Health Information

ADVANCE HEALTH CARE DIRECTIVE