Equality Health Center

Patient Intake Form

Please correct the errors described below.
(Disregard if you already have appointment)
(medications, metals, iodine, latex)

We understand that many of the questions in this section of your history below are of a sensitive nature and are very personal. We ask these questions to all of our clients regardless of age, gender or partner status. We respect your right not to answer any questions that make you uncomfortable. We believe that answering these questions openly and honestly will allow us to give you the best, most thorough and appropriate health care. All information you share with us is held in the strictest confidence. PLEASE BE ASSURED THAT THIS IS A JUDGEMENT FREE ZONE!

NOTE: EHC does not review these forms 24/7. In the event of a medical, psychiatric or personal safety emergency, call 911.

NOTE TO MINORS: If you are under 18 years of age and you have been a) involved in a sexually abusive relationship relationship; b) sexually exploited, or c) physically abused; or if you are under 13 and have been involved in a sexual relationship, we are obligated by law to call the Division of Child and Youth Services and make a report.

*If you are ANY age and would like support or information about sexual, physical or emotional abuse visit the New Hampshire Coalition Against Domestic & Sexual Violence at www.nhcadsv.org.

While our clinic recognizes a number of sexes/genders, many insurance companies and legal entities do not. Please understand that your legal name must be used on documents pertaining to insurance and billing. If your legal name is different than your preferred name, please document here. That being said, outside of insurance and billing, we will always refer to you as the name/gender identity you prefer.

EHC requests that you provide the name of someone we may contact on your behalf in the event of a serious complication or emergency. If you are a minor, this must be a parent and/or legal guardian. If you are not fluent in English, please provide the name of your interpreter or someone who can speak/understand English. It is our policy to contact this person only in the case of an emergency.

Please sign below and PRESS THE SUBMIT BUTTON AT THE VERY BOTTOM OF THIS FORM.

Please write name above and date below

PATIENTS' BILL OF RIGHTS Section 151:21 151:21 Patients' Bill of Rights. – The policy describing the rights and responsibilities of each patient admitted to a facility, except those admitted by a home health care provider, shall include, as a minimum, the following: I. The patient shall be treated with consideration, respect, and full recognition of the patient's dignity and individuality, including privacy in treatment and personal care and including being informed of them name, licensure status, and staff position of all those with whom the patient has contact, pursuant to RSA 151:3-b. II. The patient shall be fully informed of a patient's rights and responsibilities and of all procedures governing patient conduct and responsibilities. This information must be provided orally and in writing before or at admission, except for emergency admissions. Receipt of the information must be acknowledged by the patient in writing. When a patient lacks the capacity to make informed judgments the signing must be by the person legally responsible for the patient. III. The patient shall be fully informed in writing in language that the patient can understand, before or at the time of admission and as necessary during the patient's stay, of the facility's basic per diem rate and of those services included and not included in the basic per diem rate. A statement of services that are not normally covered by medicare or medicaid shall also be included in this disclosure. IV. The patient shall be fully informed by a health care provider of his or her medical condition, health care needs, and diagnostic test results, including the manner by which such results will be provided and the expected time interval between testing and receiving results, unless medically inadvisable and so documented in the medical record, and shall be given the opportunity to participate in the planning of his or her total care and medical treatment, to refuse treatment, and to be involved in experimental research upon the patient's written consent only. For the purposes of this paragraph "health care provider'' means any person, corporation, facility, or institution either licensed by this state or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist, or psychologist, and any officer, employee, or agent of such provider acting in the course and scope of employment or agency related to or supportive of health care services. V. The patient shall be transferred or discharged after appropriate discharge planning only for medical reasons, for the patient's welfare or that of other patients, if the facility ceases to operate, or for nonpayment for the patient's stay, except as prohibited by Title XVIII or XIX of the Social Security Act. No patient shall be involuntarily discharged from a facility because the patient becomes eligible for medicaid as a source of payment. VI. The patient shall be encouraged and assisted throughout the patient's stay to exercise the patient's rights as a patient and citizen. The patient may voice grievances and recommend changes in policies and services to facility staff or outside representatives free from restraint, interference, coercion, discrimination, or reprisal. VII. The patient shall be permitted to manage the patient's personal financial affairs. If the patient authorizes the facility in writing to assist in this management and the facility so consents, the assistance shall be carried out in accordance with the patient's rights under this subdivision and in conformance with state law and rules. VIII. The patient shall be free from emotional, psychological, sexual and physical abuse and from exploitation, neglect, corporal punishment and involuntary seclusion. IX. The patient shall be free from chemical and physical restraints except when they are authorized in writing by a physician for a specific and limited time necessary to protect the patient or others from injury. In an emergency, restraints may be authorized by the designated professional staff member in order to protect the patient or others from injury. The staff member must promptly report such action to the physician and document same in the medical records. X. The patient shall be ensured confidential treatment of all information contained in the patient' personal and clinical record, including that stored in an automatic data bank, and the patient's written consent shall be required for the release of information to anyone not otherwise authorized by law to receive it. Medical information contained in the medical records at any facility licensed under this chapter shall be deemed to be the property of the patient. The patient shall be entitled to a copy of such records upon request. The charge for the copying of a patient's medical records shall not exceed $15 for the first 30 pages or $.50 per page, whichever is greater; provided, that copies of filmed records such as radiograms, x-rays, and sonograms shall be copied at a reasonable cost. XI. The patient shall not be required to perform services for the facility. Where appropriate for therapeutic or diversional purposes and agreed to by the patient, such services may be included in a plan of care and treatment. XII. The patient shall be free to communicate with, associate with, and meet privately with anyone, including family and resident groups, unless to do so would infringe upon the rights of other patients. The patient may send and receive unopened personal mail. The patient has the right to have regular access to the unmonitored use of a telephone. XIII. The patient shall be free to participate in activities of any social, religious, and community groups, unless to do so would infringe upon the rights of other patients. XIV. The patient shall be free to retain and use personal clothing and possessions as space permits, provided it does not infringe on the rights of other patients. XV. The patient shall be entitled to privacy for visits and, if married, to share a room with his or her spouse if both are patients in the same facility and where both patients consent, unless it is medically contraindicated and so documented by a physician. The patient has the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, including choice of room and roommate, except when the health and safety of the individual or other patients would be endangered. XVI. The patient shall not be denied appropriate care on the basis of race, religion, color, national origin, sex, age, disability, marital status, or source of payment, nor shall any such care be denied on account of the patient's sexual orientation. XVII. The patient shall be entitled to be treated by the patient's physician of choice, subject to reasonable rules and regulations of the facility regarding the facility's credentialing process. XVIII. The patient shall be entitled to have the patient's parents, if a minor, or spouse, or next of kin, or a personal representative, if an adult, visit the facility, without restriction, if the patient is considered terminally ill by the physician responsible for the patient's care. XIX. The patient shall be entitled to receive representatives of approved organizations as provided in RSA 151:28. XX. The patient shall not be denied admission to the facility based on medicaid as a source of payment when there is an available space in the facility. XXI. Subject to the terms and conditions of the patient's insurance plan, the patient shall have access to any provider in his or her insurance plan network and referral to a provider or facility within such network shall not be unreasonably withheld pursuant to RSA 420-J:8, XIV. Source. 1981, 453:1. 1989, 43:1. 1990, 18:1-6; 140:2, XI. 1991, 365:10. 1992, 78:1. 1997, 108:6; 331:3- 8. 1998, 199:2; 388:5, 6. 2001, 85:1, eff. Aug. 18, 2001. 2009, 252:1, eff. Sept. 14, 2009. 2013, 265:3, eff. Jan. 1, 2014.

NOTICE OF PRIVACY PRACTICES Equality Health Center (EHC) is committed to safeguarding the privacy of the health information and the confidentiality of your visit. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The Health Insurance Portability and Accountability act of 1996 (HIPAA) requires that we give our patients notice outlining our privacy practices, patient rights regarding personal and protected health information, and our legal obligations regarding personal information (PHI) EHC reserves the right to revise this notice. EHC may use your health information for the purpose of: 1. Treatment A staff member or health care provider may record and use your health information within our medical chart in order to provide the best possible care for you. 2. Payment A staff member may use your personal health information in order to determine and obtain accurate payment, as in calling your insurance company to verify benefits. 3. Operations EHC may use your health information to operate our business. Examples are: a) Quality Assurance: Staff may use and review your health information in order to assess the quality of the care that you received. b) Business Operations: EHC collaborates with some business associates to run our organization. An example would be an accountant. All EHC business associates are required by law to safeguard your information. Disclosures required by law: 1. Law Enforcement EHC may disclose health information when required to do so by law. For example, your health information could be disclosed in response to a valid subpoena. EHC would make every effort to inform you prior to any disclosure required by law. 2. Public Health As required by law, we may disclose your health information to public health authorities in order to prevent or control disease, injury, disability, or abuse. 3. Food and Drug Administration (FDA) We may disclose health information to the FDA. An example would be if a product, drug, or device prescribed caused adverse effects or proved to be defective. Your Health Information Privacy Rights Although your health record is the physical property of EHC, the information belongs to you. You have the right to: • Request restrictions on certain uses and disclosures of your information. • Inspect and have a copy of your medical record. (Please note: EHC retains records on clients for: 10 years after last date of service/treatment for adults over the age of 18. For minors, EHC retains records for 10 years after the date of legal maturity, which in New Hampshire is age 18.) • Request an amendment to the information in your medical record. • Request confidential communications. You may request that we contact you at certain locations. We will make every attempt to honor your request. EHC reserves the right to provide safe healthcare by being able to contact you. • Authorize the disclosure of your personal health information for uses other than treatment, payment, or operations. You may revoke any authorization. • You have a right to receive a copy of this notice. • You have the right to file a complaint without fear of retaliation or penalty. EHC’s Responsibilities: We are required to: • Maintain and respect the privacy of your health information. • Abide by the terms of this notice. • Attempt to accommodate your requests regarding restrictions on the use and disclosure of your health information. • Notify you if we are unable to agree to a requested restriction or amendment. • Accommodate reasonable requests you have for confidential communications. How to File a Complaint If you believe your privacy rights have been violated by EHC you may file a complaint by writing to any of the following: 1. HIPPAA Privacy Officer at EHC 38 South Main Street, Concord, NH 03301 or by fax (603) 228-6255. 2. New Hampshire Department of Health and Human Services, Health Facilities Administration, 129 Pleasant Street, Concord, NH 03301. 3. Secretary of the Department of Health and Human Services at 200 Independence Ave., SW, Washington, DC 20201. You will not be penalized or retaliated against for filing a complaint. Revised August 2016

EQUALITY HEALTH CENTER CLIENT FINANCIAL AGREEMENT Welcome to the Equality Health Center (EHC). We appreciate that you have chosen our health center and would like to ensure that you have a clear understanding of your rights and responsibilities in regards to payments. EHC is a nonprofit organization that is committed to offering high quality health care at an affordable price. We are respectful of individual financial circumstances and will work with you to try and resolve monetary challenges. In order to offer affordable services, we depend upon our clients to make prompt payment for their care. Please take the time to read the information below and do not hesitate to ask questions. A copy of this statement will be provided upon request. Payment and Methods of Payment: Payment in full is expected at the time of service including fees for all lab services and medications. We accept Visa, MasterCard Discover, money orders and cashiers checks and the following insurances: Anthem/BCBS, Harvard Pilgrim, United Health, Cigna, United New Hampshire Medicaid, Wellsense, New Hampshire Health Families and Ambetter. Medical Insurance: If you choose to have EHC contact your primary insurance carrier (identified above), we will directly bill your company. Please note the following exceptions regarding payment through your insurance company: ❖ When your insurance company was contacted, EHC staff was provided an estimate of what your insurance plan will cover. Your insurance company makes the final determination of your eligibility and insurance benefits once the claim is submitted. You will be responsible for promptly paying any of the charges not covered by insurance., ❖ Confidentiality cannot be guaranteed if insurance is billed especially when the statement of your services is sent to the holder of your insurance policy. Equality Health Center has no control over this process. New Hampshire Medicaid: NH Medicaid plans cover family planning visits, which includes some of the services provided by EHC. NH Medicaid does not include abortions and abortion related costs. If you qualify, EHC will bill Medicaid. If you do not qualify, you will be responsible for payment of services. If you are having financial difficulties, please talk with a EHC staff member who may be able to help you problem solve. Past Due Accounts: Accounts are considered past due 30 days following the date of services. If you are unable to pay your balance, please call EHC and ask to speak to our client-billing specialist to make payment arrangements. If after 90 days, you have not paid your balance, EHC reserves the right to restrict future services to you and to turn your account over to a private debt collector. EHC reserves the right to add a $25 fee for any check returned due to insufficient funds or any other reason. Client Agreement • I agree to pay Equality Health Center for all fees resulting from services provided. • If I choose to use my insurance plan or NH Medicaid, I am responsible for providing Equality Health Center with accurate information. I also authorize Equality Health Center to access benefit information and file claims on my behalf for services provided. • I hereby assign medical benefits, including government-sponsored programs, and any other health plans to which I am entitled to be paid directly to the Equality Health Center. • I understand that I am responsible to pay for services not covered by my insurance plan or NH Medicaid. • I understand that, if requested, the Equality Health Center staff will work with me to identify ways to pay for services. • I will inform the Equality Health Center of any change of my financial status. Revised August 2016

Please press the submit button below to send your information privately to EHC. If you have any questions, call 603-225-2739.

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