Patient Registration Forms

PATIENT INFORMATION

PARENT INFORMATION

Insurance Information

Primary Insurance

Secondary Insurance

Insurance Authorization and Assignment (Please read and Sign)

I attest that the information I have given here is correct and true to the best of my knowledge. I hereby assign benefits to be paid directly to the doctor, and authorize him/her to furnish information regarding my visits to my insurance carrier. I understand that I am responsible for my entire bill unless this form is complete.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

MEDICAL HISTORY

Welcome to The Children's Clinic of Klamath! Please take the time to fill out this form as accurately as possible so we can most appropriately address your child’s health needs. Thank you!

BIRTH HISTORY—Pregnancy

BIRTH HISTORY—Delivery/Newborn Period Delivery

PATIENT MEDICAL HISTORY

PATIENT SURGICAL HISTORY

FAMILY HISTORY

Have any family members had the following conditions?

(Mother, Father, Sibling(s), Maternal Grandma, Maternal Grandpa, Paternal Grandma, Paternal Grandpa, Other)

If yes, please provide the needed information below. Please select each condition that applies. If none, please mark the "No Known Problems" checkbox.

AUTHORIZATION TO TREAT IN THE ABSENCE OF PARENT OR GUARDIAN

I authorize the following person(s):

to be bring my child to the office visit and/or be present at any exam and consent to treatment by any provider at The Children's Clinic of Klamath. This authorization is for my child/children:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

FINANCIAL POLICY
The Children's Clinic of Klamath

The primary goal of our practice is to provide the finest pediatric care to the children and young adults in our community. Since our practice has obligations that must be met, we ask that you agree to abide by our payment policies. Insurance coverage is an agreement between you and your insurance company for the payment of medical services. You are responsible for understanding your coverage benefits and guidelines for obtaining medical services. You are ultimately responsible for full payment of professional services, laboratory charges, or associated costs incurred at the visit.

For your convenience, we accept cash, check, Visa, and MasterCard

• Insured Patients: Please come to all appointments with the necessary insurance information/card(s) so that we have the information to bill the insurance in a timely and accurate manner. If the information is not provided in a timely manner and the clinic is unable to bill for the charges within the time limits set by the insurance companies, the balance will become your responsibility.
• Newborns: Please contact your insurance company as soon as possible after the birth of your child. Most health plans allow 30 days to add your newborn otherwise you may have to wait until an open enrollment period to add coverage for your new baby.
• Self Pay Patients: If you do not have proof of insurance, you will be considered a self pay patient. For those who have no insurance, the Oregon Vaccines for Children program will cover the cost of vaccines but not the administration fee of $30.00 per vaccine.
• New Patients: All self pay new patients will be required to pay, in full, at the time of the visit. This policy also applies to existing patients with delinquent accounts, accounts turned to a collection agency, claimed bankruptcy, or have balances written off to bad debt.

WELL CHILD APPOINTMENTS: When children are scheduled for preventative care (well child visits), it is parents responsibility to verify insurance benefits before the appointment. We have staff that can assist you with this. If the insurance does not cover routine services such as vaccinations and well child visits, the balance will be your responsibility. We cannot change billing codes once the insurance has been billed for a service.

**** IF YOUR CHILD IS SICK ON THE DAY OF THE WELL CHILD APPOINTMENT, WE WILL SEE YOUR CHILD FOR THE SICK VISIT AND RESCHEDULE THE WELL VISIT. IF YOU WISH US TO SEE THE CHILD FOR BOTH THE SICK AND WELL VISITS ON THE SAME DAY YOUR INSURANCE WILL NOT COVER BOTH VISITS AND YOU WILL BE RESPONSIBLE FOR THE BALANCE.

Medicaid patients will be required to agree in writing.

• Co-payments: If your insurance has a co-payment, it is due at the time of your visit.
• Non-Sufficient Funds: When checks are returned to us because of nonsufficient funds a $50.00 charge will be added to your account and you will be asked to pay by cash or credit card for future visits.
• All balances are due within 30 days of the first statement. Please contact our Billing Office at 541-882-1540 if you have any concerns regarding your bill so that we can discuss it with you.
• Delinquent accounts more than 90 days past due, with no payments and/or broken payment arrangements are subject to collection activity. You will be notified in writing and by phone (if possible) prior to any action.
• Collections: In the unfortunate event that we need to assign an account to a collection agency we will be adding an additional fee of $150.00 to the delinquent balance on the account. Any discounts will be added back to balance and amount sent to the collection agency will be the full fee. The second time a family is assigned to a collection agency the family will be dismissed from our practice.
• We know circumstances arise preventing you from coming to your appointment. Please call 24 hours in advance to cancel or reschedule appointments. There will be a $50.00 fee charged to your account if you fail to cancel/reschedule 24 hours in advance. If a family has ongoing missed appointments without contacting the clinic, the family may be dismissed from our practice.

During these challenging financial times, it is our desire to keep your medical expenses at a manageable level. Should you receive a bill from us and find yourself in a financial bind, please call the billing office at 541-882-1540 to discuss setting up a payment plan. If more charges are added to the balance, new payment arrangements will need to be made. We are happy to help and are here to assist you.

As guarantor of the patient, I understand the clinic's financial policy as stated above and agree to pay for all services rendered in accordance with the terms and conditions set forth in the financial policy of The Children's Clinic of Klamath.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

AUTHORIZATION TO RELEASE MEDICAL RECORDS

Two years of records sent to other physicians/clinics are provided free of charge. Any additional records (more than 2 years) will be charged at the rate set by Oregon Statute. ORS 192.521: $30 for copying 10 or fewer pages of written material, $0.50 per page for pages 11 through 50, $0.25 for each additional page. Postage fees if sent by first class mail, thumb drive or disc charges if requested. Please make payment to The Children's Clinic of Klamath. Your request will be processed within 30 days after payment.

I Authorize My Health Information to Be

The Children's Clinic of Klamath will accept medical records via secure fax to 541-882-1637 or securely emailed to , or mail.

–OR–

I understand that certain information cannot be released without specific authorization as required by State/Federal law. By INITIALING, I authorize the release of the following protected or sensitive information. Patients 14+ must provide initials.

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment, or referral information.

You are under no obligation to sign this form, and you may refuse to do so. Treatment, payment, enrollment, or eligibility benefits may not be conditioned on signing this authorization, with the exception of obtaining information in connection with eligibility or enrollment in a health plan.

You have the right to revoke this authorization at any time by providing a written request for revocation to The Children's Clinic of Klamath Medical Records Department. If you revoke the authorization, the revocation will not affect any disclosures that were made prior to processing the revocation request.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Minors - a minor patient’s signature is required in order to disclose information related to reproductive care, sexually transmitted diseases, HIV/AIDS drug and/or alcohol abuse, mental health.

The Children's Clinic of Klamath
2580 Daggett Avenue
Klamath Falls, OR 97601
541-884-8030
records@childrensclinicofklamath.opdirect.net secure email

Please list the name and date of birth of all children in your family.

InteliChart

Patient Portal

Access to records is available for all children under 18 years of age. When a patient turns 14 years old in the State of Oregon, by law, their record automatically becomes private. They may grant permission to a parent or guardian to access their chart by signing an additional release form.

Please list the name and email of the parent/guardian that would like access to the patient portal:

Authorization for Other Caregivers

The person listed below is designated as our agent to give consent (verbal or written) to surgical or medical treatment by any licensed physician or provider at The Children's Clinic of Klamath for my minor child. Such consent may include but is not limited to, administration of necessary anesthetics, medical treatment, test, X-ray examinations, transfusions, injections, immunizations or drugs and the performing of whatever procedures may be deemed necessary or advisable.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide the authority to consent thereto as our said agent and the above-named child͛s attending physician, in the exercise of their best judgment, may deem advisable. This authorization shall remain effective unless revoked in writing by the undersigned.

The undersigned hereby authorize (person other than parent/guardian):

My signature below certifies that all of the above information is true and accurate.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

For office use only:

CLINIC POLICIES

Thank you for choosing The Children's Clinic of Klamath for your medical care. Please review our policies and procedures below and sign where indicated.

• Patients must arrive 15 minutes before their scheduled appointment time and provide their insurance card, photo ID and insurance copay if applicable at check-in. We have a contractual obligation to your insurance company to collect copays at time of service.
• • A no show or late cancellation fee of $50 will be charged to patients who do not provide 24 hour notification to cancel an appointment or for patients who miss their appointment. After 3 no shows or late canceled appointments you may be discharged from the practice.
• • If you arrive 15 or more minutes late to your appointment you may be asked to reschedule.
• • Copays not paid at time of service will be assessed a $15.00 fee.
• If your child is being seen for a Well Child Check and you have other concerns that are not related to routine, wellness care, those concerns may generate other charges to your insurance or you may need to schedule an additional appt.
• Any outstanding balances due to deductibles, co-payments, and services not covered by your insurance are your responsibility. All balances must be paid promptly. If you are unable to pay the balance in full please contact our billing department to make payment arrangements. Non-payment of charges will result in the account being turned over to a collections agency and your family will be discharged from the practice.
• Our phones are open 7:30am-5:30pm Monday-Friday. After hours, we offer a telephone triage consultation service that puts you in touch with a pediatric-trained triage nurse. You may reach the service by calling our office and following the instructions. We offer this as a service to our patients and to reduce the high costs and time spent for unnecessary trips to the emergency room. You may also find many answers to your questions on our website: www.cckonline.com.
• Please allow 3 business days for all forms and prescription refill requests.
• The Children's Clinic of Klamath will only use and disclose health information about the patient in compliance with the HIPAA Act. You are entitled to receive a copy of the Notice of Privacy Practices as outlined by Federal Regulations. You have the right to ask that some or all of the patient’s health information may not be used or disclosed in the manner described in the Notice of Privacy Practices. The Children's Clinic of Klamath is not required by law to agree to such requests. Your signature below acknowledges that you are aware of your rights in accordance to HIPAA.
• We keep a record of the health care services we provide your child. You may ask us to see and copy that record (copy charges may apply). You may also ask us to correct that record. We will not disclose your child's record to others unless you direct us to do so or unless the law authorizes or compels us to do so. Contact the Record's Custodian to see the record or to get more information about it.

authorize and consent to routine and emergency medical treatment for my child when deemed necessary by qualified medical personnel. This authorization will be in effect until revoked in writing by me.

I acknowledge with my signature that I have read and understand the information above.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

14 YEARS AND OLDER RELEASE FORM

Patient Portal

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

NOTICE OF PRIVACY PRACTICES

As required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU/YOUR CHILD (AS A PATIENT OF THE PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR HEALTH INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY

A. OUR COMMITMENT TO YOUR PRIVACY

Throughout this document, “you” refers to you and/or your children (if an unemancipated minor). Our practice is dedicated to maintaining the privacy of your protected health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide you. We are required by law to maintain the confidentially of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your protected health information. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your PHI
• Your privacy rights in your PHI
• Our obligation concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice had created or maintained in the past, and for any records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Privacy Officer
The Children's Clinic of Klamath
2580 Daggett Avenue
Klamath Falls, OR 97601
541-884-1224

C. WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS:

1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have a laboratory test (such as blood or urine test), and we may use the results to help us reach a diagnosis. We may use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

2. Health Information Exchange. A health information exchange (HIE) is a system that electronically moves and exchanges patients' PHI between participating health care providers who have been approved to use the system and who have a unique log-in and password. The Children's Clinic of Klamath participates in the Jefferson Health Information Exchange (JHIE).

JHIE facilitates the sharing of PHI among authorized health care providers (e.g. health systems, hospitals, physician offices and labs) and health information organizations for treatment, payment and operative (TPO) purposes. JHIE is a secure system designed according to nationally recognized standards, and in accordance with federal and state laws that protect the privacy and security of the information being exchanged. Your PHI is available to authorized health care providers through JHIE unless you decline to participate or "opt out" by completing a JHIE Request for Non Participation Form.

JHIE will not sell or disclose your PHI to any third party for any commercial or activity unrelated to TPO, as defined by federal laws (HIPAA and HITECH), including, but not limited to marketing or fundraising activities.

What does this mean to you?

JHIE offers major benefits to you and your family. These benefits may include:

• Emergency Treatment. Medical staff immediately knows about your health problems, medications and prior visits, helping them take care of you without delay, which may save your life.
• More Complete and Accurate Information. JHIE gives your doctors greater access to the information needed to diagnose your health problems earlier. They will know more about you and your health history before they recommend treatment or refer you to a specialist.
• Improved Care. Access to information about care you received elsewhere gives a better, more complete picture of your health and provides information needed to provide the best care possible. That means your doctors make sure the treatment they give doesn't interact badly with other treatments you may be receiving.
• Becoming More Involved in Your Care. You can take a more active role in your health and in the health of your family. When your doctor has more information about you, you can talk to him/her about your health and treatments you receive from other providers. Together you can make decisions about your health care or that of your family members.

Payment. Our practice may use and disclose your PHI in order to bill and collect payment for services and items you may have received from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if you insurer will cover, or pay for, your treatment. We may also use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collections efforts. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for services and items you may have received from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if you insurer will cover, or pay for, your treatment. We may also use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collections efforts.

Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.

Health Care Operations. Our practice may use and disclose your PHI to operate our business. As examples of the way in which we may use and disclose your PHI for our operations, our practice may use your PHI to evaluate the quality of care you receive from us, or conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations.

Treatment Options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.

Release of Information to Family/Friends. Our practice may release your health information to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to our office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.

Disclosures Required By Law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

D. WE MAY USE AND DISCLOSE YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES:

1. Public Health Risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

• Maintaining vital records, such as births and deaths Reporting child abuse or neglect
• Preventing or controlling disease, injury or disability
• Notifying a person regarding potential exposure to a communicable disease
• Notifying a person regarding a potential risk for spreading or contracting a disease or condition.
• Reporting reactions to drugs or problems with products or devices
• Notifying individuals if a product or device they may be using has been recalled
• Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose the information if the patient agrees or we are required to or authorized by law to disclose this information
• Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Heath Oversight Activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor governmental programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law Enforcement. We may release PHI if asked to do so by a law enforcement official:

• Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement
• Concerning a death we believe has resulted from criminal conduct
• Regarding criminal conduct at our office In response to a warrant, summons, court order, subpoena or similar legal process
• To identify/locate a suspect, material witness, fugitive or missing person
• In an emergency, to report a crime (including the location or victim(s) of the crime, and the description, identity or location of the perpetrators)

5. Deceased Patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information in order for funeral directors to perform their jobs.

6. Organ and Tissue Donations. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ and tissue donations and transplantation if you are an organ donor.

7. Serious Threats to Health or Safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

8. Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

9. National Security. Our practice may disclose your PHI to federal officials for intelligence and national securities activities authorized by law. We may also disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

10. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

11. Workers Compensation. Our practice may release your PHI for worker’s compensation and similar programs.

E. YOUR RIGHTS REGARDING YOUR PHI:

1. Confidential Communications. You have the right to request that our practice communicates with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask us that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to: Privacy Officer, The Children's Clinic of Klamath, 2580 Daggett Ave, Klamath Falls, OR 97601, 541-884-1224, specifying the requested method of contact or the location where you wish to be contacted. Our practice will accommodate a reasonable request. You do not need to give a reason for your request.

2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when information is necessary to treat you. In order to request a restriction in our use or disclosure of your health information, you must make your request in writing to: Privacy Officer, The Children's Clinic of Klamath, 2580 Daggett Ave, Klamath Falls, OR 97601. Your request must describe in a clear and concise fashion:

1. the information you wish restricted;
2. whether you are requesting to limit our practice’s use, disclosure or both; and
3. to whom you want the limits to apply.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. In care of teenagers, certain confidential information may not be released to parents. This includes information about sexual activity, contraception, sexually transmitted diseases, and other information gathered in a setting where the physician/provider has agreed to confidentiality with the patient. You must submit your request in writing to Privacy Officer, The Children's Clinic of Klamath of the Northwest, 2580 Daggett Avenue, Klamath Falls, OR 97601 in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the cost of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct the reviews.

4. Amendment. You may ask us to amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Privacy Officer, The Children's Clinic of Klamath of the Northwest, 2580 Daggett Avenue, Klamath Falls, OR 97601. You must provide us with a reason that supports your request for amendment. Our practice may deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for non-treatment, non-payment or non-operations purposes. Use of your PHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain and “accounting of disclosures”, you must submit your request in writing to Privacy Officer, The Children's Clinic of Klamath of the Northwest, 2580 Daggett Avenue, Klamath Falls, OR 97601. All requests for an “accounting of disclosures” must state a time period, which may not be longer that six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period if free of charge, but our practice may charge you for additional list within the same 12-month period. Our practice will notify you of the cost involved with additional request, and you may withdraw your request before you incur any cost.

6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this Notice at anytime. To obtain a paper copy of this Notice, contact Front Office Staff/Office Assistant, The Children's Clinic of Klamath of the Northwest, 2580 Daggett Avenue, Klamath Falls, OR 97601.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the Privacy Officer, The Children's Clinic of Klamath of the Northwest, 2580 Daggett Avenue, Klamath Falls, OR 97601. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your health information for the reason described in the authorization. Please note, we are required to retain records of your care.

Right to Request Non-Participation in Health Information Exchange:

Health Information Exchanges are used to send and receive medical reports including labs, x-rays etc through secured exchanges in order to provide other authorized medical facilities such as specialists, hospitals and other physicians involved in your care as quickly as possible. Patients who do not want their health information to be accessible to authorized health care providers through the Reliance Information Exchange may choose not to participate or "opt-out". If you choose to opt-out and complete aRequest for Non-Participation Form, health care providers will not be able to search for your records electronically except in the case of a medical emergency. If you previously chose to opt-out and would now like to begin participating again, or "opt-in", you may.

If you chose at a later date to opt-in, your health information will be accessible to authorized health care providers. Your request will not be processed immediately so when you opt-in your information may not immediately be available to your provider(s).

Again, if you have any questions regarding this notice or our health information privacy policies, please contact:

Privacy Officer
The Children's Clinic of Klamath
2580 Daggett Avenue
Klamath Falls, OR 97601
541-884-1224

HIPPA Acknowledgment

I have read and understand the above HIPAA form and consent to its terms and I was offered a copy of the form.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.