Sibling 1Age Healthy Deceased Other Medical Condition
Sibling 2Age Healthy Deceased Other Medical Condition
Sibling 3Age Healthy Deceased Other Medical Condition
Sibling 4Age Healthy Deceased Other Medical Condition
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 RIGHTSWhen it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
YOUR CHOICESFor 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.
OUR USES AND DISCLOSURESHow do we typically use or share your health information? We typically use or share your health information in the following ways.
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.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
CHANGES TO THE TERMS OF THIS NOTICEWe 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 website, and we will mail a copy to you.
Effective Date: September 23, 2013
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
WHAT CAN AN ADVANCE HEALTH CARE DIRECTIVE DO?
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?
WHERE CAN I GET THE ADVANCE HEALTH CARE DIRECTIVE FORMS?
WHO SHOULD HAVE A COPY OF THE ADVANCE HEALTH CARE DIRECTIVE?
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:
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
PLEASE INITIAL EACH OF THE FOLLOWING STATEMENTS AND SIGN BELOW.
Initial Here* I hereby consent to health care encompassing routine diagnostic procedures, medical, dental treatment, mental health and other health services rendered to me by KCS/ Korean Community Services, Inc. and its duly authorized agents and personnel. I hereby give permission to KCS/ Korean Community Services, Inc. and its duly authorized agents and personnel to provide first aid and to take the appropriate measures, including contacting the Emergency Medical Service (EMS) system and arranging for transportation to the nearest emergency medical facility as deemed necessary. Initial Here* I understand that the practice of medicine and surgery and the rendering of health care including dental and mental health are not an exact science and that no guarantees have been made as to the results of treatments, examinations or other health services rendered by this clinic.I have read, initialed and understand all the above statements and voluntarily give my consent for treatment and acknowledgment of receipt of privacy practices.
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, 451 W. Lincoln Avenue, Suite 100, Anaheim, CA 92805.
I acknowledge receipt of the Notice of Privacy Practices, Member’s Rights and Responsibilities, and Advanced Medical Directives.
It is my understanding that Congress passed a law entitled the Health Insurance Portability and Accountability Act (“HIPAA”) that limits disclosure of my protected medical information. This authorization is being signed because it is crucial that my medical providers readily give my protected medical information to the persons designated in this authorization in order to allow me the advantage of being able to discuss and obtain advice from my family and/or friends. Therefore, pursuant to 45 CFR 164.501(a)(1)(iv) a covered entity (being a health care provider as defined by HIPAA) is permitted to disclose protected health information pursuant to and in compliance with this valid authorization under 45 CFR Sec. 164.508.
I, Full Name* , hereby authorize all covered entities as defined in HIPAA, including but not limited to a doctor, (i.e. physician, podiatrist, chiropractor, or osteopath,) psychiatrist, psychologist, dentist, therapist, nurse, hospitals, clinics, pharmacy, laboratory, ambulance service, assisted living facility, residential care facility, bed and board facility, nursing home, medical insurance company or any other health care provider or affiliate, to disclose the following information:
All health care information, reports and/or records concerning my medical history, condition, diagnosis, testing, prognosis, treatment, billing information and identity of health care providers, whether past, present or future and any other information which is in any way related to my healthcare. Additionally, this disclosure shall include the ability to ask questions and discuss this protected medical information with the person or entity who has possession of the protected medical information even if I am fully competent to ask questions and discuss this matter at the time. It is my intention to give a full authorization to ANY protected medical information to the persons named in this authorization.
This authorization shall terminate on the first to occur of: (1) two years following my death or (2) upon my written revocation actually received by the covered entity. A copy or facsimile of this original authorization shall be accepted as though it were an original document. I hereby release any covered entity that acts in reliance on this authorization from any liability that may accrue from releasing my protected medical information and for any actions taken by my authorized persons.
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:
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 PROCEDUREIn 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 OPTIONSPay your bill online:
Pay by phone:
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.
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 email@example.com. Business hours are M-F 9AM-5PM.
I agree to the terms of KCS Health Center’s payment policy.
INFORMED CONSENT FOR TELEMEDICINEBy signing this form, I understand the following:
POSSIBLE RISKSAs 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, 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 TELEMEDICINEI 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.
If oral informed consent is provided, please document the following: