THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

1. Get a copy of your health and claims records.
   1. You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
   2. We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
2. Ask us to correct health and claims records.
   1. You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
   2. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
3. Request confidential communications
   1. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
   2. We will consider all reasonable requests and must say "yes" if you tell us you would be in danger if we do not.
4. Ask us to limit what we use or share
   1. You can ask us not to use or share certain health information for treatment, payment, or our operations.
   2. We are not required to agree to your request, and we may say "no" if it would affect your care.
5. Get a list of those with whom we’ve shared information
   1. You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
   2. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a  reasonable, cost-based fee if you ask for another one within 12 months.
6. Get a copy of this privacy notice
   1. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
7. Choose someone to act for you
   1. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
   2. We will make sure the person has this authority and can act for you before we take any action.
8. File a complaint if you feel your rights are violated
   1. You can complain if you feel we have violated your rights by contacting us using the information on page 1.
   2. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
   3. We will not retaliate against you for filing a complaint.

YOUR CHOICES
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

1. In these cases, you have both the right and choice to tell us to:
   1. Share information with your family, close friends, or others involved in payment for your care
   2. Share information in a disaster relief situation
   3. Contact you for fundraising efforts
   4. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
2. In these cases we never share your information unless you give us written permission:
   1. Marketing purposes
   2. Sale of your information

OUR USES AND DISCLOSURES
How do we typically use or share your health information? We typically use or share your health information in the following ways.

1. Help manage the health care treatment you receive
   1. We can use your health information and share it with professionals who are treating you.
   2. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
2. Run our organization
   1. We can use and disclose your information to run our organization and contact you when necessary.
   2. We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
   3. Example: We use health information about you to develop better services for you.
3. Pay for your health services
   1. We can use and disclose your health information as we pay for your health services.
   2. Example: We share information about you with your dental plan to coordinate payment for your dental work.
4. Administer your plan
   1. We may disclose your health information to your health plan sponsor for plan administration.
   2. Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge
5. Help with public health and safety issues
   1. We can share health information about you for certain situations such as:
      1. Preventing disease
      2. Helping with product recalls
      3. Reporting adverse reactions to medications
      4. Reporting suspected abuse, neglect, or domestic violence
      5. Preventing or reducing a serious threat to anyone's health or safety
6. Do research
   1. We can use or share your information for health research.
7. Comply with the law
   1. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
8. Respond to organ and tissue donation requests and work with a medical examiner or funeral director
   1. We can share health information about you with organ procurement organizations.
   2. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
9. Address workers’ compensation, law enforcement, and other government requests
   1. We can use or share health information about you:
      1. For workers' compensation claims
      2. For law enforcement purposes or with a law enforcement official
      3. With health oversight agencies for activities authorized by law
      4. For special government functions such as military, national security, and presidential protective services
10. Respond to lawsuits and legal actions
    1. We can share health information about you in response to a court or administrative order, or in response to a subpoena.
11. Conduct outreach, enrollment, care coordination and case management
    1. We can share your information with other government benefits programs like Covered California for reasons such as outreach, enrollment, care coordination, and case management.
12. Appeal a DHCS decision
    1. We can share your information if you or your provider appeal a DHCS decision about your health care.
13. Apply for full scope Medi-Cal
    1. If you are applying for full scope Medi-Cal benefits, we must check your immigration status with the U.S. Citizenship and Immigration Services (USCIS).
14. Join a managed care plan
    1. If you are joining a new managed care plan, we can share your information with that plan for reasons such as care coordination and to make sure that you can get services on time.
15. Administer our programs
    1. We can share your information with our contractors and agents who help us administer our programs.
16. Comply with special laws
    1. There are special laws that protect some types of health information such as mental health services, treatment for substance use disorders, and HIV/AIDS testing and treatment. We will obey these laws when they are stricter than this notice. We will never market or sell your personal information.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

OUR RESPONSIBILITIES

1. We are required by law to maintain the privacy and security of your protected health information.
2. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
3. We must follow the duties and privacy practices described in this notice and give you a copy of it.
4. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

CHANGES TO THE TERMS OF THIS NOTICE
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

Effective Date: September 23, 2013

1. You have the right to receive information about KCS’s services, benefits, practitioners, providers, member rights and responsibilities and clinical guidelines. You have a right to receive this information in a manner and format that is understandable and appropriate to your condition.
2. You have the right to receive oral interpretation services free of charge for any materials in any language.
3. You have the right to be treated with respect as an individual in a manner that protects your privacy and dignity, regardless of race, gender, veteran status, religion, marital status, national origin, physical disabilities, mental disabilities, age, sexual orientation, or ancestry.
4. You have the right to have all communication regarding your health information kept confidential by KCS staff and contracted providers and practitioners, to the extent required by law.
5. You have the right to participate with practitioners and providers in your own treatment planning and decision making regarding your care, and to include family members when appropriate and/or requested. Treatment planning discussions may include all appropriate and medically necessary treatment options, regardless of benefit design and/or cost implications.
6. You have the right to decide who will make medical decisions for you if you cannot make them.
7. You have the right to give or refuse consent for treatment and give or refuse consent for communication of treatment information to your PCP and/or other behavioral health providers.
8. You have the right to obtain information regarding your own treatment record with signed consent in a timely manner and have the right to request an amendment or correction be made to your medical records.
9. You have the right to appeal a KCS authorization decision resulting in denial of any aspect of care or service.
10. You have the right to submit a complaint or concern (or have a designee do so on your behalf), verbally or in writing, about the care you have received.
11. You have the right to have questions or concerns answered completely and courteously by your providers and KCS staff.
12. You have the right to contact KCS Health Center to obtain a copy of member rights and responsibilities statement. You may make recommendations about the member rights and responsibilities statement to the KCS.
13. You have the right to participate in the Member Advisory Council. You may make recommendations about the member rights and responsibilities statement to the council.
14. You have the right to exercise these rights without having your treatment adversely affected in any way.
15. You have the right to be free from restraint and seclusion as a means of coercion, discipline, convenience, or retaliation.
16. You have the right to access emergency care 24 hours a day, 7 days a week.

1. You are responsible for choosing a primary care provider and site for the coordination of all your medical care.
2. You are responsible for carrying your HP/MCO member ID card and showing the card whenever you seek treatment.
3. You are responsible for understanding your benefits, what’s covered and what’s not covered.
4. You are responsible for understanding that you may be responsible for payment of services you receive that are not included in the Covered Services List for your coverage type.
5. You are responsible for providing information, to the best of your ability, to KCS Health Center and treating providers that is necessary to ensure effective behavioral healthcare for you.
6. You are responsible, to the best of your ability, to understand your behavioral healthcare needs and participate in your treatment including developing, following and revising as necessary, mutually agreed upon treatment and aftercare plans.
7. You are responsible for contacting your Behavioral Health Provider, if you have one, if you are experiencing a mental health or substance abuse emergency.

WHAT IS AN ADVANCE HEALTH CARE DIRECTIVE?
An Advance Directive is a legal document that allows an individual to state in advance their wishes should they become unable to make healthcare decisions. In California, an Advance Directive consists of two parts

1. Appointment of an agent for healthcare
2. Individual health care instructions.

WHAT CAN AN ADVANCE HEALTH CARE DIRECTIVE DO?

• It allows you to make treatment choices now in the event you need mental health treatment in the future. You can tell your doctor, institution, provider, treatment facility, and judge what types of treatment you do and do not want.
• You can select a friend or family member to make mental health care decisions, if you cannot make them for yourself
• It can improve communications between you and your physician
• It may reduce the need for long hospital stays
• It becomes a part of your medical record

WHO CAN FILL OUT AN ADVANCE HEALTH CARE DIRECTIVE?
Any person 18 years or older who has the “capacity” to make health care decisions. “Capacity” means the person understands the nature and consequences of the proposed healthcare, including the risks and benefits.

WHEN DOES AN ADVANCE HEALTH CARE DIRECTIVE GO INTO EFFECT?
In California, an Advance Health Care Directive is indefinite. You can change your mind at any time, as long as you have the “capacity” to make decisions. It is a good idea to review your Advance Health Care Directive early to make sure your wishes are stated.

DO I HAVE TO HAVE AN ADVANCE HEALTH CARE DIRECTIVE?
No. It is just a way of making your wishes known in writing, while you are capable. Your choices are important.

WHERE DO I GET LEGAL ADVICE ABOUT AN ADVANCE HEALTH CARE DIRECTIVE?

• Your Attorney
• Disability Rights California at www.disabilityrightsca.org
• Mental Health America of Los Angeles (213) 413-1130, Ext. 26
• Protection and Advocacy

WHERE CAN I GET THE ADVANCE HEALTH CARE DIRECTIVE FORMS?

• Your Attorney
• Stationary Stores
• https://www.nrc-pad.org/states/california/
• KCS

WHO SHOULD HAVE A COPY OF THE ADVANCE HEALTH CARE DIRECTIVE?

• You (Your Advance Health Care Directive should be kept in a safe place, but easily accessible.)
• Your agent (The person designated to make health care decisions if you are unable to do so.)
• Each of your health care providers
• Each of your mental health providers

It is important that you keep track of who has a copy of your Advance Health Care Directive in case you make changes in the document.

Complaints concerning non-compliance with the advance health care directive requirements may be filed with the California Department of Health Services (DHS) Licensing and Certification by calling 1-800-236-9747 or by mailing to P.O. Box 997413, Sacramento, California 95899-7413.

KCS is a non-profit agency which is designed to provide health care to those families in Orange County who have no other means of obtaining health care. Our clinic is staffed by both paid and volunteer doctors and nurses. To better serve you, we ask you for your cooperation in following the policies listed below. If you are unable to follow these guidelines, or find them unacceptable, another health care provider may be better able to meet your needs. I understand and agree to do the following:

1. I will inform KCS if my address, telephone number(s), income or insurance changes within 30 days of any change.
2. I will give KCS 24 hours’ notice if I will be unable to keep my appointment.
3. All patients should arrive 15-20 minutes prior to their appointment time. Arriving late for an appointment will result in being rescheduled for the next available time.
4. If I miss 3 appointments without notifying KCS, I understand that I may no longer be able to receive services.
5. I authorize any KCS health care professional to disclose any personal health information to other health care professionals, when medically necessary.
6. I authorize the staff of KCS to disclose my registration and screening information for the purpose of obtaining low cost health care at another facility.
7. I understand that I am solely responsible for the following through of testing and treatment ordered by providers at KCS. I understand that if I fail to follow the physician’s orders, my treatment may be unsuccessful.
8. I understand that if I am uncooperative, verbally abusive, intoxicated or behave in an inappropriate manner, I may not be eligible for services at KCS

I have received a full explanation of services and I understand and agree to all of the above. I understand I can be dismissed from the clinic as a patient if I have given wrong information, misleading information or if I fail to follow the policies above. I hereby and voluntarily consent to authorize the center’s healthcare providers to provide health care services to me. The health care services may include, without limitation, routine physical and mental assessment; diagnostic and monitoring tests and procedures; examinations and medical and/or dental treatment; routine laboratory procedures and tests; x-rays and other imaging studies; administration of medications; and procedures and treatments prescribed by the center’s healthcare providers. The health care services also may include counseling necessary to receive appropriate services including family planning. I understand that there are certain hazards and risks connected with all forms of treatment, and my consent is given knowing this. I understand that this consent is valid and remains in effect as long as I am a patient of the center, until I withdraw my consent, or until the center changes its services and asks me to complete a new consent form.

My signature on this form indicates that

1. I certify that I have read and fully understand the foregoing consent and that the facts indicated above are true.
2. I realize that although every effort will be made to keep all risks and side effects to a minimum, risks, side effects, and complications can
   be unpredictable both in nature and severity.
3. I understand that midlevel providers may be involved in my treatment and I consent thereto.
4. I hereby voluntarily give my consent to Treatment at the Center

1. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plan to KCS clinic Physicians.
2. This assignment will remain in effect until revoked by me in writing.
3. A photocopy of this assignment is to be considered as valid as an original.
4. I understand that I am financially responsible for all charges whether or not paid by said insurance. If my deductible is met and an insurance billing concern arises, I will discuss this issue with the KCS Billing Department and/or my insurance company would be financially responsible for all charges that may arise.
5. I hereby authorize said assignee to release all information necessary to secure the payment.

PLEASE INITIAL EACH OF THE FOLLOWING STATEMENTS AND SIGN BELOW.

By signing this form, you acknowledge receipt of the Member’s Rights and Responsibilities, Notice of Privacy Practice, and Advanced Medical Directives. Our Member’s Rights and Responsibilities, Notice of Privacy Practice, and Advanced Medical Directives provide information about your right and responsibilities at our clinic and how we may use and disclose your medical information. We encourage that you read these three forms in full.

If you have any questions about our Member’s Rights and Responsibilities, Notice of Privacy Practice, and Advanced Medical Directives please contact KCS Health Center, 7212 Orangethorpe Ave. Suite 9A, Buena Park, CA 90621/ (714)503-6550.

I acknowledge receipt of the Member’s Rights and Responsibilities, Notice of Privacy Practice, and Advanced Medical Directives.

Under HIPAA, my personal Protected Health Information (PHI) is protected from unwarranted disclosure without my (or my designated Guardian’s) voluntary consent. Pursuant to HIPAA (specifically 45 CFR Sec. 164.501(a)(1)(iv)), KCS Inc., a covered health care provider (or other entity as defined by HIPAA), is permitted to disclose all or part of my PHI in accordance with this authorization (45 CFR Sec. 164.508).

Furthermore, the Recipient(s) designated below is prohibited from making any further disclosure of my PHI unless expressly authorized by HIPAA or state and federal law and regulations. Multiple release requests may be made to separate Recipients at any given time and remain in effect independently of this authorization.

Revocation of this authorization can be done by a separate, subsequent written revocation, except to the extent that the identified service provider already has taken action based on this authorization. If no expiration date is specified below, this authorization will expire two (2) years after the date signed.

Notwithstanding protections under HIPAA, I understand KCS or any person who works for KCS, as authorized by State and Federal law and regulations, is required to report to proper authorities any suspected child abuse or neglect, suspected elderly abuse or neglect, threats to commit a crime or harm, or threatening to harm myself or others, or against KCS or any person who works for KCS.

This information may be released to"

Disclose To (Recipient):

KCS Health will seek all payments for services rendered to patients who are deemed able to pay. When a balance is owed by the patient, the payment is considered “Self Pay” and payment in full is expected. An account is determined to be Self-Pay if any of the following are true:

• There is no insurance on record
• All expected payments from the insurance carriers, Medicare and other third-party payers have been exhausted
• A patient has not responded timely to requests for information/documentation needed to determine eligibility or household income
• Patient does not provide information requested from third party insurers to process claims

All self-pay accounts process through a 28 day statement cycle.

Due to the frequent delays in the Medi-Cal eligibility processes, KCS Health may perform Medi-Cal eligibility checks on all Self-Pay accounts after your visit. If Medi-Cal coverage is identified, the account will be reclassified to Medi-Cal from Self-Pay and billed to MediCal.

All Self-Pay accounts will be sent a minimum of three statements spanning at least 90 days of time, with the last contact notifying the patient that if the bill remains unpaid, in 30 days their account will be handed over to a collection agency that is contracted with KCS Health for further assistance in the collection efforts. KCS Health will provide other notification methods that constitute a genuine effort to contact the party responsible for the obligation, including, for example, telephone calls, statement letters, and in person reminders.

For all mailed statements that have been returned as undeliverable, reasonable efforts will be made to determine and update the accurate mailing address. These efforts will be documented on each patient account and will follow the above mentioned with regards to notification methods.

PAYMENT PROCEDURE
In Person / Telehealth Visits - All patient visit fees are due during check-in at time of service. For patients with a balance, you are responsible for payment to clear the remaining owed at this time as well. Once services have been rendered and you are checked-out, if any estimated patient responsibility amount has been incurred, please pay the balance at the front check-in desk before leaving KCS Health, otherwise you will receive a statement in the mail reflecting the current balance due from this visit. Telehealth Visits is due at the time of the visit and may be paid by being transferred to the Billing department or Front office after your Telehealth Visit. You can also call the number below, otherwise you will receive a statement in the mail reflecting the current balance due from the telehealth visit, amount is due upon receipt.

*KCS Health Center has the right to apply the FULL SLIDING FEE SCALE at the next visit, if and when patient has not fulfilled their nominal fees at the time of the previous visit, and has not produced any proof of income by their next appointment*

PAYMENT OPTIONS
Pay your bill online:

• PayPal / KCS Payment Portal (online credit card): https://www.kcsinc.org/payment-portal/
• Zelle Pay (bank to bank pay): zelle@kcsinc.org

Pay by phone:

• Contact the KCS Health Call Center, (714) 503-6550

Pay in person:
Any of our KCS Health Centers listed below will accept In Person payments in the form of Cash, Mastercard or Visa. We DO NOT ACCEPT ANY PERSONAL CHECKS. Please be sure to have a current photo ID with you for verification.

• Lincoln: 451 W. Lincoln Ave., Ste. 100 Anaheim, CA 92805, (714) 503-6550
• Orangethorpe: 7212 Orangethorpe Ave. Suite 9A, Buena Park, CA 90621, (714) 503-6550
• Commonwealth: 8352 Commonwealth Ave., Buena Park, CA 90621 (714) 503-6550
• MacArthur: 19742 MacArthur Blvd., Suite 250 Irvine, CA 92612 (714) 503-6550

PAYMENT PLANS

• Payment plans are available and will need to be discussed with the billing department.
• If after receiving a statement and you are unable to pay your bill in full, please contact KCS Health Billing department for more information at (714) 503-6550, or send an email to billing@kcsinc.org.

If you have any questions regarding your statement or account, please contact our KCS Health Billing department at (714) 503-6550, or send an email to billing@kcsinc.org. Business hours are M-F 9AM-5PM.

I agree to the terms of KCS Health Center’s payment policy.

INFORMED CONSENT FOR TELEMEDICINE
By signing this form, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine during my care at any time, without affecting my right to future care or treatment.
3. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.
4. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
5. I understand that it is my duty to inform my physician of electronic interactions regarding my care that I may have with other healthcare providers.
6. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

EXPECTED BENEFITS

• Improved access to medical care by enabling a patient to remain in his/her home (or at a remote site) while the physician provides
  services
• More efficient medical evaluation and management
• Patients save time by avoiding travel and reduce stress by staying in the comforted as well as safety of their own home

POSSIBLE RISKS
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors

In rare cases, such as a pandemic (i.e. COVID-19) and under the guidance of Federal and State authorities, KCS Health Center may use any necessary means for Telehealth that may or may not be HIPAA compliant

PATIENT CONSENT TO THE USE OF TELEMEDICINE
I have read and understood the information provided above regarding telemedicine and have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care. If this consent is in force (has not been revoked) KCS Health Center may provide health care services to me via telemedicine without the need for me to sign another consent form.

I hereby authorize KCS Health Center to use telemedicine in the course of my diagnosis and treatment.

I, the legal guardian named below, authorize KCS to provide medical care for the patient named above, including immunizations, physical examinations, and testing/treatment for the purpose of medical diagnosis and treatment, which is deemed advisable by and is to be rendered by the providers and staff of KCS.

KCS will be unable to treat any minor (under the age of 18) without a parent or legal guardian present. Minors 12 years and older may consent to medical diagnosis, or treatment of the following: infectious or communicable diseases which must be reported to the local health officer; STDs, rape or HIV testing, mental health therapy or drug or alcohol related problems. Minors of any age may consent to medical diagnosis and/or treatment of the following: contraception, pregnancy, and diagnosis or treatment of sexual assault.

I give permission to the following adult family members and/or caregivers to authorize medical care and treatment on my behalf in the event I cannot personally accompany my child. I can revoke this permission at any time by informing the medical staff.

Once you click the "SUBMIT" button below, you will be routed to a SUPPLEMENTAL INTAKE based on the additional medical service you requested above.