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.

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 at BACHC 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 that BACHC participates in 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 with BACHC, as described in BACHC’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.

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 their inability to pay for such services. It also requires Health Centers to 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 BACHC with the information it needs to receive reimbursement for the treatment or services it provides to me;
• Requesting consideration for discounted fees under BACHC’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’s Registration and Benefits team;
• Assisting the registration and Benefits team with any application for insurance or public benefits that I may be entitled to;
• Paying my co-payment (if applicable) when I check-in for my appointment and paying my deductible or any other fees that may be owed at the conclusion of the medical visit;
• Paying my fees for medical and behavioral health received at BACHC in full at the time of service, either upon check-in or at check-out as requested by BACHC if 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.

By signing below, you confirm agreement with all documents you've initialed at Bartz-Altadonna CHC, including "Consents and Acknowledgements," "Patient Rights and Responsibilities," "Notice of Privacy Practices," "Patient Messaging Consent," "Financial Obligation Acknowledgement," "HIPAA Authorization," and "Permission for Nonurgent Pediatric Care (If applicable)". You also permit BACHC to use and disclose your health information asper Federal Privacy Standards and understand your HIPAA rights regarding the use of this information for treatment, payment, and healthcare operations.

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 signing below the “revocation of authorization” or inform BACHC in writing, 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 and drug/alcohol treatment is highly sensitive and requires the specific authorization I have provided by marking the boxes above. A separate authorization form would need to be completed if I were to request to see my own Mental/Behavioral Health Information.
• 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.