WHAT SERVICES ARE YOU SEEKING? - Affinity...

Prevention Fast-Track ☐REGISTRATION FORM

Welcome to Affinity Health Center! We are happy you have chosen us for your care. To register, please complete this form. Several of the items below help us ensure that we are meeting the needs of the population we serve, so please be as thorough

as you can. Let us know if you have any questions or if you need help completing this form.

WHAT SERVICES ARE YOU SEEKING? Check all that apply

Primary Medical Care Mental Health Counseling Dental

HIV Medical Care Case Management Nutrition

PATIENT INFORMATION

Date of Birth: Month Day YearSocial Security Number

- -

Legal Name:First Middle Initial Last

Name you would like to be called, if different from legal name: ______________________________________________________

Street Address Apartment #

City State Zip Code County

Affinity Health Center will send you mail at this address. We believe it is important for us to communicate with you regarding services, payments, etc.

Primary Phone number _______________________________ Type: Home Mobile/Cell Work/Business Friend/Relative

OK to text: Yes No

Secondary Phone number _____________________________ Type: Home Mobile/Cell Work/Business Friend/Relative

OK to text: Yes No

Other Phone number _________________________________ Type: Home Mobile/Cell Work/Business Friend/Relative

OK to text: Yes No

Guarantor of Patient:

☐ Self ☐ Parent: ____________________________________________________________________________________

☐ Other: ____________________________________________________________________________________________

To comply with our Federal grants, we report demographic information collected (aggregated) from all of our patients.What is your annual income? ____________________ Head of Household? Self Other: ______________________

Please check one of the following boxes that best matches your total HOUSEHOLD income:Co-pay Household Size 1 Household Size 2 Household Size 3 Household Size 4

$5.00 No income to $981 monthly

(0-11,770 annually) No income to $1,327 monthly


(0 – 20,090 annually) No income to $2,020 monthly

(0 - 24,250 annually)

$10.00 $981 - 1,226 monthly

(11,771 - 14,713 annually) $1,328 - 1,659 monthly


(20,091 - 25,113 annually) $2,021 – 2,526 monthly

(24,251 - 30,313 annually)

$15.00 $1226 - 1,471 monthly


(19,914 – 23,895 annually) $2,093 - 2,511 monthly


(30,314 - 36,375 annually)

$30.00 $1,471 - 1,716 monthly




(36,376 - 42,438 annually)

$45.00 $1,717 – 1,962 monthly


(27,879 - 31,860 annually $2,930 - 3,348 monthly


(42,439 - 48,500 annually)

Pay at 100%

$1,962 or more monthly(23,541 or more annually)




500 Lakeshore Parkway | Rock Hill, SC 29730T: 803.909.6363 | F: 803.909.6364 | affinityhealthcenter.org

Co-pay Household Size 5 Household Size 6 Household Size 7 Household Size 8

$5.00 No income to $2,367 monthly




(0-40,890 annually)

$10.00 $2,368 - 2,959 monthly

(28,411-35,513 annually) $2,714 - 3,392 monthly



(40,891-51,113 annually)

$15.00 $2,960 - 3,551 monthly(35,514-42,615 annually)

$3,393 - 4,071 monthly(40,714-48,855 annually)











Pay at 100%





If your Household size is greater than ONE, please complete the following section. Use the back if more space is needed.

First Name Last Name Relationship to PatientDependent? Yes No Monthly Income: ___________________________________________ Household Member? Yes No Date of Birth: _____________________________ SSN: _____________________________________________________Gender: Male Female Transgendered



Have you been to the hospital or Emergency Room in the last 12 months? Yes NoHave you seen a medical provider (Doctor, Mental Health Counselor, etc.) in the last 12 months? Yes No

If you have answered Yes to the above questions, a signed release of medical records is needed.

PAYMENT FOR SERVICESPLEASE PROVIDE YOUR INSURANCE CARD AT THE TIME OF REGISTRATION.

INSURED? YES NO

If you do not have insurance, you must meet with an Affinity Health Center Case Manager. You may be eligible for public insurance or a discount for your services. In order to determine your eligibility, you must provide income documentation.

LEGAL NAME AND SEX Affinity Health Center will bill the insurance company with your legal name and legal gender marker.

INSURANCEINFORMATION

Name of Your Insurance Company: ____________________________________________________________________________________

Insurance Identification Number: ______________________________________________________________________________________

Insurance Group Number: ____________________________________________________________________________________________

Insurance Contact Telephone Number (On Back Of Your Card): ______________________________________________________________

In whose name is your insurance? Self Other

If other, please provide Name and Date of Birth of Guarantor: ________________________________________________________________

-Guarantor’s SSN: ________________________________________________________________

Is the responsible party an Affinity Health Center Patient? Yes No

DEMOGRAPHICSHousing Status Agricultural Status_____________

Doubling up/Friends or Family Public Housing Dependent of Migrant Not Agricultural Worker Homeless Shelter Transitional Other Dependent of Seasonal Seasonal Worker Not Homeless Street/Homeless Unknown Migrant Worker

Language

English Spanish Italian Japanese Chinese French German

Need translation services Sign Language Am hearing disabled and need interpreter services

Other (please specify): ________________________

Race

African American/Black (including Africa and Caribbean)

Caucasian/White (including Middle Eastern)

American Indian or Alaska Native (including all Original Peoples of the Americas)

Asian (including Indian

subcontinent and Philippines)

Native Hawaiian

Other Pacific Islander

Unreported/Refused to Report

Multiple Races

Hispanic

Other; specify:

________________________

Ethnicity Non-Hispanic/ Non-Latino Hispanic or Latino (including Spain) Unreported/Refused to Report

Veteran? Yes No Unknown If yes, are you eligible for benefits? Yes No Unknown

Birth Sex (Please Check One) Male Female

To be completed by patients over 16

Do you Identify as Transgender? Yes No Preferred pronoun: He/him She/her Other: _____________

Sexual Orientation Gay/Lesbian Straight Bi-sexual Other: ____________

EMERGENCY CONTACTPlease provide contact information for the person you want us to contact in the event of an emergency. We will identify ourselves as

Affinity Health Center in the event of an emergency.First Name: Last Name: Relationship:

Street Address: Apt.#

City: State: Zip Code:

Home#: Work#:

By signing my name below, I am acknowledging that I have completed each with correct and honest information.(Patient or Guardian)

Signature: Date:

Additional household members if your household size is greater than ONE (continued from other side).








First Name Last Name Relationship to Patient

Dependent? Yes No Monthly Income: ___________________________________________ Household Member? Yes No Date of Birth: _____________________________ SSN: _____________________________________________________Gender: Male Female Transgendered

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

GENERAL CONSENT TO TREATI voluntarily agree to receive services from Affinity Health Center, and authorize the providers of AHC to provide such care, treatment, or services as are considered necessary and advisable for me. I understand that I should participate in the planning for my care and that I have a right to refuse interventions, treatment, care, services or medications at any time to the extent the law allows. I know that the care I will receive may include tests, injections, and other medications, etc., that are based on established medical criteria, but not free of risk. HIV Testing is included as a routine part of care unless I, the patient, elect to decline testing which should be done by notifying the medical provider. Should it be necessary, I authorize AHC staff to obtain emergency medical assistance for me from the Emergency Medical Service and/or hospital.

INTEGRATED MODEL OF CAREAHC offers a wide variety of services for its patients. I understand that in order for me to get the best care possible, programs within AHC may share information concerning my health to ensure the quality and continuity of my care across service areas. I also understand that services are delivered by a multi-disciplinary team under the supervision of a physician. I authorize my provider to discuss with parties outside AHC information including diagnosis(es), case history, physical examinations, treatments, and hospitalizations—deemed necessary and appropriate to deliver medical care to me. I request that my protected health information be communicated with others directly involved in my care. The designated care provider listed will keep a copy of this document as a permanent part of my medical record which will be copied as required in order to allow communication of my protected health information, in accordance with HIPAA. I understand that my health care providers will use judgment in determining the minimum amount of information that must be shared to care for me.

SATELLITE SERVICESI consent to have the Family Resource Center staff at AHC satellite sites assist in the provision of services to me including, but not limited to, interpretation, faxing records, and providing administrative support to AHC staff. All Family Resource Center staff members are business associates of Affinity Health Center and are bound by HIPAA.

PATIENT RIGHTS AND RESPONSIBILITIES I have been given a copy of the AHC Patient Rights and Responsibilities document and understand that both the Rights and Responsibilities laid out in that document must govern my interactions at AHC. I also understand that AHC and I are responsible for adhering to the Rights and Responsibilities. I understand that I have a right to file a complaint with AHC, as described in the Patient Rights. The Patient Rights contains information about being a patient at AHC and services that AHC offers.

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

ACKNOWLEDGEMENT OF DUTY TO REIMBURSE AHC FOR HEALTH CARE SERVICESI understand that AHC offers a Discounted Fee Schedule to individuals who are deemed unable to pay based on their level of income. In order to be eligible for AHC’s Discounted Fee Schedule, I will need to provide AHC with documents establishing that I meet income eligibility requirements.

By signing my name below, I am acknowledging that I have read and fully understand each of the separate paragraphs set forth above and consent freely, voluntarily and without coercion. I understand that I may revoke my consent at any time, except to the extent that action has been taken in reliance on this consent.

Patient or Guardian Signature: Date:

Print Name (Print relationship also, if other than patient): DOB:


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NOTICE OF PRIVACY PRACTICES

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.

Affinity Health Center is required by law to maintain the privacy of protected health information ("PHI") and to provide individuals with notice of Affinity Health Center's legal duties and privacy practices with respect to PHI. PHI is information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices ("Notice") describes how Affinity Health Center may use and disclose PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to PHI about you.

Affinity Health Center is required to follow the terms of this Notice. Affinity Health Center will not use or disclose PHI about you without your written authorization, except as described in this Notice. Affinity Health Center reserves the right to change our practices and this Notice and to make the new Notice effective for all PHI Affinity Health Center maintains, including PHI created or received before the changes were made. Affinity Health Center will provide any revised Notice to you (either at any Affinity Health Center location or through the Affinity Health Center Privacy Officer).

Affinity Health Center will post a copy of the current Notice in each Affinity Health Center location. In addition, the current Notice and any revised Notice will be posted on Affinity Health Center's website at www.affinityhealthcenter.org.

YOUR HEALTH INFORMATION RIGHTSYou have the following rights with respect to PHI about you:

Breach of Unsecured PHI . Affinity Health Center will provide written notification of a breach of your unsecured PHI. You have the right to receive written notification of a breach where your unsecured PHI has been accessed, used, acquired, or disclosed to an unauthorized person as a result of such breach, and the breach compromises the security and privacy of your PHI. Unless specified in writing by you to receive this breach notification by electronic mail, we will provide this notification by first-class mail or, if necessary, by such other substituted forms of communication allowable under the law.

Obtain a paper copy of the Notice upon request. You may request a copy of this Notice at any time. You may obtain a paper copy at any Affinity Health Center location or by writing to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer.

Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of PHI about you by completing a Request for Additional Restriction on Use or Disclosure of Protected Health Information form (available at any Affinity Health Center location) and delivering it to the Affinity Health Center location(s) which you believe maintains PHI about you or sending it to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer. Affinity Health Center is not required to agree to additional restrictions that are requested, unless your request is to restrict disclosure of your PHI to a health plan and such disclosure is for payment or healthcare operations, is not required by law, and the PHI pertains only to an item or service that has been paid for in full by you.

Inspect and obtain a copy of PHI. You have the right to access and copy PHI about you that is contained in a designated record set for as long as Affinity Health Center maintains the PHI. The designated record set usually will include treatment, prescription and billing records. To inspect or copy PHI about you, you must complete a Request for Access to Protected Health Information form (available at any Affinity Health Center location) and deliver it to the Affinity Health Center location(s) which you believe maintains PHI about you or send it to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer. Affinity Health Center may charge you a fee for the costs of copying, mailing and supplies that are necessary to fulfill your request. Affinity Health Center may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed.

http://www.affinityhealthcenter.org/

Request an amendment of PHI. If you feel that PHI Affinity Health Center maintains about you is incomplete or incorrect, you may request that Affinity Health Center amend it. You may request an amendment for as long as Affinity Health Center maintains the PHI. To request an amendment, you must complete a Request to Amend Protected Health Information form (available at any Affinity Health Center location) and deliver it to the Affinity Health Center location(s) which you believe maintains PHI about you or send it to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer. You must include a reason that supports your request. Affinity Health Center may deny your request for amendment if the PHI:

Was not created by Affinity Health Center, unless the person or entity that created the PHI is no longer available to make the amendment;

Is not part of the PHI kept by or for Affinity Health Center; Is not part of the PHI which you would be permitted to inspect and copy; or Is accurate and complete.

If Affinity Health Center denies your request for amendment, you have the right to submit to Affinity Health Center a statement of disagreement with the decision and Affinity Health Center may give a rebuttal to your statement.

Receive an accounting of disclosures of PHI . You have the right to receive an accounting of the disclosures Affinity Health Center made of PHI about you in the past six years for most purposes other than treatment, payment, or health care operations. The accounting will exclude certain disclosures, such as disclosures made directly to you, disclosures you authorize, disclosures to friends or family members involved in your care, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must complete a Request for an Accounting of Disclosures form (available at any Affinity Health Center location) and deliver it to the Affinity Health Center location(s) which you believe maintains PHI about you or send it to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer. Your request must specify the time period, but may not be longer than 6 years. The first accounting you request within a 12 month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. Affinity Health Center will notify you of the cost involved and you may choose to withdraw or modify your request at that time. Certain other exceptions may apply for PHI maintained in an electronic health record.

Request communications of PHI by alternative means or at alternative locations. You have the right to request how and where Affinity Health Center contacts you about PHI. For instance, you may request that Affinity Health Center contact you about medical matters only in writing or at a different residence or post office box. To request confidential communication of PHI about you, you must notify Affinity Health Center in writing, preferably by completing a Request for Alternative Communications on Use or Disclosure of Protected Health Information form (available at any Affinity Health Center location) and deliver it to the Affinity Health Center location(s) which you believe maintains PHI about you or send it to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer. Your request must state how or where you would like to be contacted. Affinity Health Center will accommodate all reasonable requests. If you are not able to complete the written request, you may notify Affinity Health Center by phone at which time the staff member will note the change in your record.

EXAMPLES OF HOW AFFINITY HEALTH CENTER MAY USE AND DISCLOSE PHI1. The following are descriptions and examples of ways Affinity Health Center may use and disclose PHI without

your authorization:

Affinity Health Center will use PHI for treatment. Example: Information obtained by a nurse or physician will be recorded in your health record and used to determine the best treatment for you. The healthcare team will document your treatment goals, actions taken and clinical observations.

Affinity Health Center will use PHI for payment. Example: Affinity Health Center may bill you or a third-party payor for the cost of services rendered to you and prescription medications dispensed to you. The information on or accompanying the bill may include information that identifies you, your diagnoses, treatments and supplies used.

Affinity Health Center will use PHI for health care operations. Example: Affinity Health Center may use information in your health record to monitor the performance of the health care team providing treatment to you. This information will be used in an effort to continually improve the quality and effectiveness of the health care service Affinity Health Center provides.

2. Affinity Health Center is likely to use or disclose PHI for the following purposes:

Business associates. There are some services provided by us through contracts with business associates. Examples may include archive records storage, software support and maintenance companies, as well as select telecommunications companies assisting in transmission of electronic data for payment/treatment. When these services are contracted for, Affinity Health Center may disclose PHI about you to our business associate, subject to state authorization requirements, so that they can perform the job Affinity Health Center has asked them to do and bill you or your third-party payor for services rendered. To protect PHI about you, Affinity Health Center requires the business associate to appropriately safeguard the PHI.

Communication with individuals involved in your care or payment for your care. Subject to state authorization requirements, health professionals such as pharmacists, using their professional judgment, may disclose to a family member, other relative, close personal friend or any person you identify, PHI relevant to that person's involvement in your care or payment related to your care. You have the right to object to such disclosure. Any objection must be communicated in writing to the Privacy Officer.

Health-related communications. Affinity Health Center may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Food and Drug Administration (FDA). As required by law, Affinity Health Center may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Worker’s compensation. Affinity Health Center may disclose PHI about you as authorized by and as necessary to comply with laws relating to worker's compensation or similar programs established by law.

Public health. As required by law, Affinity Health Center may disclose PHI about you to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Law enforcement. Affinity Health Center may disclose PHI about you for law enforcement purposes as required by law or in response to a valid subpoena or other legal process.

Correctional institution. If you are an inmate of a correctional institution, Affinity Health Center may disclose PHI about you to the institution or its agents that is needed for your health or the health and safety of other individuals.

As required by law. Affinity Health Center must disclose PHI about you when required to do so by law.

Health oversight activities. Affinity Health Center may disclose PHI about you to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and administrative proceedings. If you are involved in a lawsuit or a dispute, Affinity Health Center may disclose PHI about you in response to a court or administrative order, subject to state authorization requirements where applicable. Affinity Health Center may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested PHI and subject to state authorization requirements where applicable.

3. Affinity Health Center is permitted to use or disclose PHI about you for the following purposes:

Coroners, medical examiners, and funeral directors. To the extent required by law, Affinity Health Center may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. Affinity Health Center may also disclose PHI to funeral directors consistent with applicable law to carry out their duties.

Organ or tissue procurement organizations. Consistent with applicable law, Affinity Health Center may disclose PHI about you to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Notification. To the extent permitted by state law, Affinity Health Center may use or disclose PHI about you to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and your general condition.

Correctional institution. If you are or become an inmate of a correctional institution, Affinity Health Center may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others and to the extent required by law.

To avert a serious threat to health or safety. Affinity Health Center may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Military and veterans. If you are a member of the armed forces, Affinity Health Center may release PHI about you as required by military command authorities who are authorized by law to receive such information. Affinity Health Center may also release PHI about foreign military personnel to the appropriate military authority to the extent required by law.

National security and intelligence activities. Affinity Health Center may release PHI about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Victims of abuse, neglect, or domestic violence. Affinity Health Center may disclose PHI about you to a government authority, such as a social service or protective services agency, if Affinity Health Center reasonably believes you are a victim of abuse, neglect, or domestic violence. Affinity Health Center will only disclose this type of information to the extent required by law, if you agree to the disclosure by written authorization required by state law, or if the disclosure is allowed by law and Affinity Health Center believes it is necessary to prevent serious harm to you or someone else or the law enforcement or public official that is to receive the report represents that it is necessary and will not be used against you.

OTHER USES AND DISCLOSURES OF PHIAffinity Health Center will obtain your written authorization before using or disclosing PHI about you for purposes other than those provided for above or as otherwise permitted or required by law. You may revoke any such authorization in writing at any time. Upon receipt of the written revocation, Affinity Health Center will stop using or disclosing PHI about you, except to the extent that has already taken action in reliance on the authorization. Use of certain types of PHI about you may only be made with your written authorization, including disclosure of your PHI for marketing purposes, or to sell your PHI.

FOR MORE INFORMATION OR TO REPORT A PROBLEMIf you have questions or would like additional information about Affinity Health Center's privacy practices, you may contact Affinity Health Center by calling the Affinity Health Center Privacy Officer at 803-909-6363 or writing to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer. If you believe your privacy rights have been violated, you can file a complaint in writing with the Affinity Health Center Privacy Officer or with the Secretary of the United States Department of Health and Human Services. There will be no retaliation for filing a complaint.

EFFECTIVE DATE: This Notice is effective as of July 1, 2014.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Acknowledgment of Receipt

By signing this form, you acknowledge receipt of the Affinity Health Center Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose protected health information ("PHI") about you and your rights regarding the use and disclosure of PHI. We encourage you to read it in full.

The Affinity Health Center Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice at one of our clinic locations, by accessing our web site at www.afinityhealthcenter.org, or by contacting Affinity Health Center at 803-909-6363.

If you have any questions about our Notice of Privacy Practices, please call the Affinity Health Center Privacy Officer at 803-909-6363 or write to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer.

I acknowledge the receipt of the Affinity Health Center Notice of Privacy Practices.

Signature: Date:

Relationship to patient: (patient/parent/conservator/guardian)

FOR AFFINITY HEALTH CENTER USE ONLY

Inability to Obtain Acknowledgment - To be completed only if no signature is obtained on Acknowledgment of Receipt of Notice of Privacy Practices.

If it is not possible to obtain the individual's acknowledgment, describe below the good faith efforts made to obtain the individual's acknowledgment, and the reasons why the acknowledgment was not obtained:

Date Acknowledgment Form Processed into Patient Profile:

Signature of Affinity Health Center employee:

http://www.afinityhealthcenter.org/

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PATIENT RIGHTS AND RESPONSIBILITIES

As a patient of Affinity Health Center, I have the following RIGHTS:

1. Considerate and Respectful Care – I have the right to receive considerate, dignified, and respectful care by all employees and volunteers of Affinity Health Center, regardless of my physical or emotional condition.

2. Privacy – I have the right to privacy in matters pertaining to my care; however there may be times when it is necessary to discuss aspects of my care with other Affinity Health Center staff or supervisors involved in my care.

3. Confidentiality – I have the right to expect that Affinity Health Center will maintain complete confidentiality of my records, according to state and federal law. Any information about my specific case that is released to another agency will only be transferred after an Authorization to Use and/or Disclose Health Information is signed by myself or my legal guardian. I further understand that my right to confidentiality does not override AHC’s “Duty to Warn” responsibility. Duty to warn includes issues such as suicidal/homicidal ideations and /or HIV partner notification.

4. Non-Discrimination - I have the right to quality services without discrimination regarding age, race, ethnicity, color, sex, religion, national origin, economic status, sexual orientation, affectional preference, or disability.

5. Response – I have the right to a response by Affinity Health Center in a timely and reasonable manner when I request services, and the right to be screened as promptly as possible for all services.

6. Access to Relevant Services – I have the right to know what services Affinity Health Center provides, how to obtain these services, and why a service may not be offered to me.

7. Active Involvement in Your Ongoing Care – I have the right to provide AHC staff members with positive or negative feedback about my care or voice my concerns or complaints about the Health Center.


PATIENT RIGHTS AND RESPONSIBILITIES (continued)

As a patient of Affinity Health Center, I have the following RESPONSIBILITIES:

1. Keeping scheduled appointments – I am responsible for keeping appointments with Affinity Health Center staff and for keeping appointments with other agencies that health center staff have scheduled for me. If I cannot keep these appointments, I am responsible for notifying health center staff and/or external service providers prior to the appointment time.

2. Respecting the Agency – I am responsible for treating all employees and volunteers of AHC with considerate care and respect. I am responsible for conducting myself in an appropriate manner while in AHC’s office, including but not limited to, respecting personal and professional boundaries, refraining from inappropriate physical contact or speech, and refraining from conduct that threatens, intimidates, or coerces any employee or volunteer. If AHC refers me to an external provider or agency for services, I am also responsible for treating those employees with respect. If I am treated inappropriately by external service providers in which AHC referred me to, I am responsible for notifying AHC staff.

3. Confidentiality - I am responsible for respecting the confidentiality of other persons I may see at AHC. Anything I may hear, see, or read about others will not be repeated, in any form, to any other person.

4. Providing Current Information – I am responsible for making sure AHC knows when my address or telephone number changes, and for informing AHC promptly whenever I have a change in my insurance or financial situation at the time of my appointment.

5. Arriving Sober: – I am responsible for being sober and not under the influence of alcohol or any other mood altering substance not prescribed by a physician when I have a scheduled meeting with any service provider.

By signing my name below, I am verifying that I understand my rights and responsibilities as a patient of Affinity Health Center. I also understand that my services with Affinity Health Center may be terminated if I do not fulfill my responsibilities within this agreement.

Patient/Guardian Signature: _____________________________ Date: ___________

PATIENT ACKNOWLEDGEMENT OF FINANCIAL OBLIGATION

Purpose: Affinity Health Center determines and monitors patients’ co-pays for all medical services provided, utilizing the Community Health Center Discounted Fee Schedule.

I understand that I am responsible for: Contributing to the cost of my care and treatment as my health insurance coverage requires and based

on my ability to pay;

Providing AHC with the information it needs to receive reimbursement for the treatment of services it provides to me;

Requesting consideration for discounted fees under AHC Discounted Fee Schedule based on my household income, and providing documentation to support eligibility for discounted fees that may be requested by AHC;

Assisting AHC staff with any application for public benefits that I may be entitled to;

Paying my co-payment, co-insurance and/or deductible (if applicable) when I check-in for my appointment and/or any other fees that may be owed;

Providing proof of income and proof of residence.

For uninsured patients: I understand that if my household income changes, I will bring documentation of those changes to AHC for assessment on the Discounted Fee Schedule.

Signature: _____________________________________________________________

Printed Name: _____________________________________________________________

Date: ____________________________________________________________

Date of Birth: _____________________________________________________________


INCOME STATEMENT

I, ____________________________________________, declare that I currently have zero (Patient name)

income. My housing is provided by ___________________________________ and his/her (Name of the person you live with)relationship to me is _________________________________. The previously named

individual does / does not provide me with financial support. (circle one)

If the person named above does provide you with financial support, please provide the

following information.

How much money do they provide you: _________________________________________

How often do they provide the money (monthly, biweekly, etc.) ___________________________

How long is the financial support supposed to last: _________________________________

In the future, should my financial situation change, I understand that I must notify Affinity Health Center as soon as possible. By signing this form, I affirm that the above information is an

accurate statement of income or assistance being provided and I understand that if I

deliberately omit or give false information that I may not be eligible for certain services or

the delivery of services could be delayed.

____________________________________________ __________________Patient or Guardian Signature Date

____________________________________________________ __________________Case Manager Signature Date

Patient URN: ________________________________


Authorization to Use and/or Disclose Health Information

Date:

Patient Name:

Address:

1. I authorize the use or disclosure of the above named patient's health information as described below.

2. Affinity Health Center is authorized to use and/or disclose the health information.

3. The type and amount of information to be used or disclosed is as follows (e.g., treatment records, prescription records, all information about the patient to date, etc.):

Medical and/or other pertinent information needed for coordination and monitoring of service and medical care

4. This information may be disclosed to and used by the following individuals or organizations (include specific information to identify individuals or organizations, e.g., address): Pediatric Patients- Please list anyone other than the patient’s Mother or Father (or Legal Guardian) that may bring the patient to the medical clinic to receive care:

5. The information will be used/disclosed for the following purpose(s) (all purposes must be listed. If patient is initiating the authorization, purpose may be described as "At the request of the patient):

To coordinate patient care

6. This authorization permits the use and disclosure of health care information for marketing purposes as described above. NO __X____ YES ______.


7. If the answer to 6 is YES, Affinity Health Center WILL _____ WILL NOT ______ receive remuneration from a third party for the use of this information.

8. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Affinity Health Center Privacy Officer or his/her designated person. I understand the revocation will not apply to information that has already been released in response to this authorization or that Affinity Health Center has already used or disclosed in reliance on this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: One year from date of initiation .

9. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment, payment, enrollment or eligibility for benefits where such a condition is prohibited. I understand that I may inspect or copy the information to be used or disclosed. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal privacy rules. If I have questions about disclosure of my health information, I can contact the Affinity Health Center Privacy Officer at 803-909-6363 or by writing to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer.

10. I understand that, to the extent information about me is disclosed from protected substance abuse records, such information is prohibited from being further disclosed unless further disclosure is expressly permitted by my written consent or as otherwise permitted by applicable law.

Signature of patient or personal representative:

If personal representative, give relationship:

FOR AFFINITY HEALTH CENTER USE ONLY - To be completed by Affinity Health Center if the above signature is that of a patient's representative.

Affinity Health Center has verified the identity of _______ [insert patient's representative name] by _______ [describe means of verification, e.g. driver's license] and that in his/her capacity of [description of authority to act, e.g. husband, wife, etc.], he or she is authorized to act on behalf of the patient.


Authorization to Use and/or Disclose Health Information

Date:

Patient Name:

Address:

1. I authorize the use or disclosure of the above named patient's health information as described below.

2. Affinity Health Center is authorized to use and/or disclose the health information.

3. The type and amount of information to be used or disclosed is as follows (e.g., treatment records, prescription records, all information about the patient to date, etc.):

a. Billing and/or insurance information

4. This information may be disclosed to and used by the following individuals or organizations (include specific information to identify individuals or organizations, e.g., address):

5. The information will be used/disclosed for the following purpose(s) (all purposes must be listed. If patient is initiating the authorization, purpose may be described as "At the request of the patient):

a. Communication needed for explaining and/or reviewing medical bills and/or insurance

payment information

6. This authorization permits the use and disclosure of health care information for marketing purposes as described above. NO __X____ YES ______.

7. If the answer to 6 is YES, Affinity Health Center WILL _____ WILL NOT ______ receive remuneration from a third party for the use of this information.


8. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Affinity Health Center Privacy Officer or his/her designated person. I understand the revocation will not apply to information that has already been released in response to this authorization or that Affinity Health Center has already used or disclosed in reliance on this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: One year from date of initiation .

9. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment, payment, enrollment or eligibility for benefits where such a condition is prohibited. I understand that I may inspect or copy the information to be used or disclosed. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal privacy rules. If I have questions about disclosure of my health information, I can contact the Affinity Health Center Privacy Officer at 803-909-6363 or by writing to Affinity Health Center, 500 Lakeshore Parkway, Rock Hill, SC 29730, Attention: Privacy Officer.

10. I understand that, to the extent information about me is disclosed from protected substance abuse records, such information is prohibited from being further disclosed unless further disclosure is expressly permitted by my written consent or as otherwise permitted by applicable law.

Signature of patient or personal representative:

If personal representative, give relationship:

FOR AFFINITY HEALTH CENTER USE ONLY - To be completed by Affinity Health Center if the above signature is that of a patient's representative.

Affinity Health Center has verified the identity of _______ [insert patient's representative name] by _______ [describe means of verification, e.g. driver's license] and that in his/her capacity of [description of authority to act, e.g. husband, wife, etc.], he or she is authorized to act on behalf of the patient.


The Affinity Health Center Patient Portal provides an easy-to-use, secure, web-based method for patients to access portions of their medical records on-line. This is available from any computer (desktop, laptop or tablet) with Internet access. When you log into the Affinity Health Center Patient Portal, you will be able to view information, including your medical conditions, medications, vital signs, lab results, allergies, and insurance policies. An email account is required to access the Patient Portal. AHC will not use your email for any other purpose without your authorization.

Register for the Affinity Health Center Patient Portal Use this form to request an Affinity Health Center Patient Portal account. Please fill-out this form as completely. Once the form has been completed it can be turned in to the receptionist. If you need assistance filling out the form please call 803-909-6363.Once you have been registered for the Affinity Health Center Patient Portal, you will receive an email from Affinity Health Center with instructions to complete your Patient Portal registration.Patient RegistrationPlease complete using CAPITAL LETTERS with one character in each block.

FIRST NAME:

LAST NAME:

DATE OF BIRTH: / /

Last 4 Digits of SSN

EMAIL ADDRESS:

ZIP (Postal) Code # -

□ Yes, I would like to be enrolled in the Affinity Health Center Patient Portal.

Please allow 3 business days for your request to be processed.An Affinity Health Center representative may contact you to verify your information.

Patient or Guardian Signature:

Today’s Date / /


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