Thank You for trusting Pomona Valley Health Centers with your health.

PATIENT DEMOGRAPHICS

PVHMC is committed to providing our patients with excellent customer service. Providing your email below enables access to the MYHEALTH Patient Portal, a safe and secure tool that provides access to a patients personal health information and medical records.

PHARMACY INFORMATION

PRIMARY INSURANCE/POLICY HOLDER INFORMATION

The undersigned certifies that he/she has read the foregoing, received a copy thereof and is the patient, the parent, the patient’s legal representative, or is duly authorized by the patient as the patient’s general agent to execute the above and accept it terms.

I understandthat I am responsible for the payment of services provided to me. Copayments will be collectedbefore services are provided.For patients without insurance coverage, full payment is required whenservices are provided. I am aware that exact charges are based upon specific services and cannot bequoted exactly before my visit. Services which are rendered outside of Premier Family Medicine Associates,Inc., such as Laboratory Testing and Radiology, will be billed separately.

If verification of my insurance coverage for Health Plan benefits cannot beverified, or is billed and denied, I will be responsible for the payment of all services provided during the visit.

Premier Family Medicine Associates, Inc. will send out statements to collect any patients balances owed. Ifpayment isnot made in a timely manner, furthers steps may be taken to obtain payment including sending theaccount to a collection service and reporting the debt to a credit bureau.

Payment methods available include: Credit Card with a Photo ID

CAIR2

Decline or Start Data Sharing Request Form

Immunization Registry Notice to Patients and Parents

Immunizations or ‘shots’ prevent serious diseases. Tuberculosis (TB) screening tests help to determine if you may have TB infection and can be required for school or work. Keeping track of shots/TB tests you have received can be hard. It’s especially hard if more than one doctor gave them. Today, doctors use a secure computer system called an immunization registry to keep track of shots and TB tests. If you change doctors, your new doctor can use the registry to see the shot/TB test record. It’s your right to limit who is able to access your records in the California Immunization Registry (CAIR).

How Does a Registry Help You?

• Keeps track of all shots and TB tests (skin tests/chest x-rays), so you don’t miss any or get too many
• Sends reminders when you or your child need shots
• Gives you a copy of the shot/TB record from the doctor
• Can show proof about shots/TB tests needed to start child care, school, or a new job

How Does a Registry Help Your Health Care Team?

Doctors, nurses, health plans, and public health agencies use the registry to:

• See which shots/TB tests are needed
• Prevent disease in your community
• Remind you about shots needed
• Help with record-keeping

Can Schools or Other Programs See the Registry?

Yes, but this is limited. Schools, child care, and other agencies allowed under California law may:

• See which shots/TB tests children need
• Make sure children meet requirements for shots and TB tests needed to start child care or school

What Information Can Be Shared in a Registry?

• patient’s name, sex, and birth date
• limited information to identify patients
• parents’ or guardians’ names
• details about a patient’s shots/TB tests or medical exemptions

What’s entered in the registry is treated like other private medical information. Misuse of the registry can be punished by law.
Under California law, only your doctor’s office, health plan, or public health department may see your address and phone number.
Health officials can also look at the registry to protect public health.

Patient and Parent Rights

It’s your legal right to ask your provider:

• to prevent other providers and schools from accessing your (or your child’s) registry records
• not to send shot appointment reminders
• for a copy of your or your child’s shot/TB test records
• who has seen the records and to change any mistakes

Please note: To request a copy of your child’s record, complete the CAIR2 Authorization to Release form and submit it to CAIRHelpDesk@cdph.ca.gov with a copy of your current ID.

Patients wishing to view a list of CAIR users who have accessed their record should contact the CAIR Help Desk at 1−800−578−7889 or CAIRHelpDesk@cdph.ca.gov.

1. Consent to Medical and Surgical Procedures: The undersigned consents to the procedures which may be performed on an outpatient basis, including emergency treatment and services, which may include but are not limited to laboratory procedures, x−ray examinations, medical or surgical treatment or procedures, anesthesia, or Pomona Valley Health Centers services rendered to the patient under the general and special instructions of the patient’s physician or surgeon. I understand that the practice of medicine is not an exact science and that diagnose and treatment may involve risks of injury or even death. I acknowledge that no guarantees have been made to me regarding the result of examination or treatment at the Pomona Valley Health Centers.

2. MYHEALTH Patient Access and Information Exchange: The Pomona Valley Health Centers makes information about your care available to you and other health care providers through online access. A brochure, entitled "What is MYHEALTH" will be provided to you at your initial visit and then annually. The brochure will explain this service and your rights. Your signature on this form acknowledges receipt of this brochure. You will receive information on how to access your patient information on MYHEALTH via e−mail following your services if you provide an email address at the time of registration.

3. Teaching Program: It is understood that the Pomona Valley Health Centers are teaching institutions and that unless the Pomona Valley Health Centers are notified to the contrary in writing, the patient may participate in the medical education program of the institution and may receive treatment by residents and/or fellows with the approval of the patient’s attending physician, and those clinical students acting under the appropriate supervision as required by such medical education and clinical training program.

4. Consent to Photograph: I consent to the taking of pictures of my medical or surgical condition or treatment and the use of pictures for scientific, educational, or research purposes.

5. Assignment of Pomona Valley Health Centers Insurance Benefits and Major Medical Insurance Benefits: The undersigned authorizes, whether he/she as agent or as patient, direct payment to the Pomona Valley Health Centers of any insurance benefits otherwise payable to or on behalf of the patient for Pomona Valley Health Centers, including emergency services if rendered, at a rate not to exceed the Pomona Valley Health Centers actual charges. It is agreed that payment to the Pomona Valley Health Centers, pursuant to this authorization, by an insurance company shall discharge said insurance company and all obligations under a policy to the extent of such payment. It is understood by the undersigned that he/she is responsible for charges not paid pursuant to this assignment.

6. Legal Relationship between the Pomona Valley Health Centers and Physician: All physicians and other providers (nurse practioners or physician assistants) of Premier Family Medicine Associates, Inc. furnishing services to the patient are independent contractors with the patient and are not employees or agents of the Pomona Valley Health Centers. The patient is under the care and supervision of his/her attending physician and it is the responsibility of the Pomona Valley Health Centers and its nursing staff to carry out the instructions of such physician, nurse practioner, or physician’s assistant.

It is the responsibility of the patient’s physician to obtain the patient’s informed consent, when required, to medical or surgical treatment, special diagnostic or therapeutic procedures, or Pomona Valley Health Centers services rendered to the patient under the general and special instruction of the physician.

7. Financial Agreement: I agree to promptly pay all bills I may incur at the Pomona Valley Health Centers in accordance with the regular rates and terms of the health centers, including its charity care and discount payment policies, if applicable. Should any account be referred to an attorney or collection agency for collection, I will pay the actual attorney’s fees and collection expenses. All delinquent accounts shall bear interest at the legal rate, unless prohibited by law.

8. Advance Directives: I have been offered information on creating an advance directive and understand that information. If I already have an advance directive, I understand that it is my responsibility to provide a copy to the Pomona Valley Health Centers.

9. Medicare: If you are a Medicare beneficiary, the following items may not be covered under the Medicare program; I) specific medical/laboratory procedures. The Federal regulations require that we inform you of the above. Your initials on this form will indicate that you have been informed, and that you are aware that you will be responsible for charges of this nature, should they occur during one of your Pomona Valley Health Centers visits.

10. Release of Information, Notice of Privacy Practices and Patient Rights/Responsibilities: The Pomona Valley Health Centers provides a Notice of Privacy Practices that explains in detail how a patient’s health information may be used and the rights you have to access or control the information. In addition, the Pomona Valley Health Centers provides information on your rights and responsibilities as a patient at the health centers. Your signature acknowledges receipt of the Notice of Privacy Practice and information on Rights/Responsibilities.

11. Marketing: The Pomona Valley Health Centers do not sell or share our patient listings with outside third parties for the purposes of marketing, under any circumstances. However, on occasion we may access our internal patient listings for the purpose of mailing information about our services, educational classes, or newsletters that may be of interest to you. We believe these practices comply with HIPPAs marketing provisions; however, we want to give you the opportunity to opt−out of receiving any marketing materials from the health centers. If you do not wish to receive these materials from the health centers, please send a written notice to our medical records departments at the health center where you see your primary care provider. Your signature indicate authorization to use your information for marketing purposes.

The undersigned certifies that he/she has read the foregoing, received a copy thereof and is the patient, the parent, the patient’s legal representative, or is duly authorized by the patient as the patient’s general agent to execute the above and accept it terms.

I have read the above statement and agree to abide by the policy as stated above.

Under the requirements if HIPPA, we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical record released to a family member or a non-family member, you must sign this release form. Signing this form will only give information to the individual(s) indicated below.

*Proper Legal Identification Required*

BY SUBMITTING THIS FORM, THE UNDERSIGNED PATIENT HEREBY CONSENTS TO THE EXAMINATION BY THE PHYSICIANS, PHYSICIAN’S ASSISTANTS AND
OTHER QUALIFIED MEDICAL PERSONNEL OF POMONA VALLEY HEALTH CENTERS OVER VIDEO AND/OR PHONE.

I HEREBY CERTIFY THAT ALL STATEMENTS ON THIS FORM ARE TRUE TO THE BEST OF MY KNOWLEDGE.

FALSIFICATION OF THE ABOVE INFORMATION MAY BE SUFFICIENT TO TERMINATE THE EXAMINATION.