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2021 Patient Registration

Patient Information

Last Name First Name M.I.

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

Transgender (F-M) Other

Mailing Address City State Zip

Physical Address City State Zip

Home Phone: Cell Phone: Work Phone:

OK to leave a message? Home Cell Work None Appointment Reminder: Phone Call Text None

Relationship Status: Single Married Partner Divorced Separated Widowed Student? Full-Time Part-time No Race: American Indian/Alaska Native Black/African American Native Hawaiian Asian White/Caucasian Other Pacific Islander Hispanic 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: Decline Straight (not lesbian/gay) Lesbian/gay Bisexual Other

How did you hear about PCHS? Friend/family member Referral Newspaper Internet Radio Community Event Other

Type 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 Zip

DOB (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.

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.

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 $15,950 $15,951 - $23,925 $23,926 - $27,913 $27,914 – $31,900 $31,901

2 $21,550 $21,551 - $32,325 $32,326 - $37,713 $37,714 - $43,100 $43,101

3 $27,150 $27,151 – $40,725 $40,726 - $47,513 $47,514 - $54,300 $54,301

4 $32,750 $32,751 - $49,125 $49,126 – $57,313 $57,314 - $65,500 $65,501

5 $38,350 $38,351 - $57,525 $57,526 – $67,113 $67,114 - $76,700 $76,701

6 $43,950 $43,951 - $65,925 $65,926 - $76,913 $76,914 – $87,900 $87,901

Are you interested in applying for the Sliding Fee Discount? Yes No

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

Emergency Contact

Emergency Contact Name: Relationship to Patient:

Home Phone: Cell Phone: Work Phone:

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Signature (Patient or Responsible Party) Date

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Print Name (Patient or Responsible Party) Date

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2021 Patient Registration

** 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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Signature (Patient or Responsible Party) Date

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Print Name (Patient or Responsible Party) Date

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2021 Patient Registration

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.*

/2021

Signature (Patient or Responsible Party) Date

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2021 Patient Registration

Patient Name: _________________________________________ Date of Birth:

Appointment Policy

We 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 during business hours 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 3 month period, a written notice will be sent to you alerting you that if a third scheduled appointment within a 3 month period is missed, the result will be that you (the patient) will only be able to have emergency walk-in care in our Dental Clinic and be able to schedule same day appointments in our Medical Clinic and Behavioral Health Center. This conditional period will be in effect for 3 months. A missed appointment is defined as:

1. Calling to cancel or reschedule the appointment after business hours the day before or the day of the scheduled appointment 2. An appointment for which the patient does not show

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 Representative This 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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Signature (Patient or Responsible Party) Date

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Signature (Patient or Responsible Party) Date

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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 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

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CONDITIONS OF SERVICE AND CONSENT FOR TREATMENT

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 Form Patient 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

THE NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE SIGN ACKNOWLEDGING THAT YOU RECEIVED A COPY. Patient Signature_______________________________________________________________

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Patient History Form

Patient Name: DOB: Healthcare Provider: Date: Dentist: Phone Number: Eye Doctor: Phone Number:

PRESCRIPTION MEDICATIONS

Prescription 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 reaction

Allergy / Drug Name Reaction

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Patient History Form

PAST MEDICAL HISTORY Please check all that apply.

Abnormal heart rhythm Anxiety Gout

Atrial fibrillation or flutter Arthritis Headaches

Heart attack Asthma Hepatitis

Stroke or TIA Blood disorder Kidney disease

Congestive heart failure Cancer Kidney stones

Heart valve disease Cataracts Liver disease

Heart murmur Chronic Lung Disease (COPD)

Prostate problems

High cholesterol Convulsions (seizures) Rheumatic fever

Clotting disorders Depression Sleep apnea

Aneurysm Diabetes (insulin dependent) TB or positive skin test

High blood pressure Diabetes (no insulin) Thyroid disease

Acid reflux/heartburn Gallstones Ulcers

AIDS or HIV Gastrointestinal Disease Mental illness

Other:

Preventative Screenings Last Date Completed Result Mammogram PAP Test Colonoscopy Prostrate Screening Bone Density Test Other:

PAST SURGICAL HISTORY

Coronary bypass Hip replacement Tonsillectomy

Breast surgery Knee replacement Pacemaker or Defibrillator

Gallbladder removal Other orthopedic surgery Hysterectomy

Hernia repair Cardiac Cath Spleenectomy

Gastric bypass Cardiac Stent

Other:

HOSPITALIZATIONS:

Date: Reason

Date: Reason

Date: Reason

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Patient History Form

FAMILY HISTORY If condition marked with (S), please specify type

Family member Father Mother Sibling(s) Father’s Father

Father’s Mother

Mother’s Father

Mother’s Mother

Alive/Deceased/Unknown A D U A D U A D U A D U A D U A D U A D U

Autoimmune disorder (S)

Blood clotting disorder (S)

Seizures

COPD

Asthma

Heart disease

Heart attack

Heart bypass

High blood pressure

Congestive heart failure

Heart rhythm problems

High cholesterol

Cancer (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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Patient History Form

Social History

Alcohol 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 on a typical day? 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

Tobacco Use: Current Former E-cigarettes/Vaping Chewing Tobacco Never

If Former Smoker: When did you start? When did you stop?

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 Thinking about quitting Not ready

Have you ever used drugs other than for medical reasons? Yes No

If yes: Is there a minor at home? Yes No Are you currently using? Yes No If no, date of last use? Are you in a treatment program? Yes No

Do you feel safe at home? Yes No Do you have a safe place to live? Yes No

Have any of your family members been hospitalized for psychiatric problems? Yes No

Are you able to pay for your daily needs? Yes No # of people in household:

Do you have any of the following impairments? Vision Hearing Speech N/A

Do you enjoy social interactions? Yes No

Do you suffer from social anxiety? Yes No

Do you have any of the following? Advanced Health Directive/Living Will Health Care POA DNR N/A

If yes, do we have it on file? Yes No

How would you rate your current oral hygiene? Good Bad Unknown

Have you seen a dentist in the last 12 months? Yes No

Would you like a referral to a dentist today? Yes No

Are you aware of medications you are taking and possible side effects?

Yes No N/A

Are you aware of any new prescription/medication changes?

Yes No N/A

Do you understand the results of any tests that you may have had done (labs, imaging)?

Yes No N/A

Do you have any barriers to taking medication as prescribed?

Yes No

If yes, what barriers? Cost Memory Side Effects Other:

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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) 262-3119

PCHS Dental (907) 283-7759

PCHS Behavioral Health–Soldotna (907) 262-3119

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Notice of Privacy Practices 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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Notice of Privacy Practices 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 Disclosures We 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 would

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Notice of Privacy Practices 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

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Notice of Privacy Practices 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.

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 Duties We 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 Officer Peninsula Community Health Services of Alaska 230 E. Marydale Ave Soldotna, Alaska, 99669 Phone: (907) 262-3119 and ask for the Compliance Officer

VIII. Reservation of Right to Change this Notice We 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 01/01/2021