Patient Rights & Responsibilities

As a patient of our Health Centers, you have the right to:

Quality care and service

• Care that is respectful of your cultural and personal beliefs without discrimination based on age, race, color, sex, country of ancestral origin, disability, religion, gender identity or expression, or sexual orientation.
• Have access to an interpreter or other language assistance
• A safe and secure environment
• Choose your primary care provider(s)
• Participate in decisions about your health care
• Right to privacy: This right includes privacy in respect to the patient’s health records according to Health Insurance Portability & Accountability Act (HIPAA) and OCH’s Privacy Notice.
• Right to self-consent: It is expected that adolescents are entitled to consent for their own care and to confidentiality under state statutes. The right to self-consent applies to:
  • A minor 14 years or older may consent to mental health services
  • A minor 15 years or older may consent to all services
  • Any minor may consent to reproductive health and family planning services for diagnosis and treatment of Sexually Transmitted Infections. If required services are not available on-site, an appropriate referral will be provided.
• Receive complete information about your health and your choices for treatment and services in a timely manner
  Complain if you have concerns about any Health Center service
• Have complaints or concerns reviewed in accordance with our established process, without fear of retaliation
• Ask about fees, charges or payment policies

As a patient of our Health Center, your responsibilities are to:

Be respectful to our Health Center staff and fellow patients

• Use appropriate language (no shouting, no personal insults, no cussing, no vulgar language, no threats, and no racial slurs) when communicating with staff members or other patients. If you are frustrated, you can request the assistance of a Behavioral Health Consultant to help with appropriate communication.
• Respect the privacy of others
• Comply with OCH’s cancellation and no-show policy. Show up for appointments on time. Notify my care team if I am running late, need to cancel an appointment, or if I need assistance with transportation.
• Do your part to keep yourself as healthy as possible by following the treatment plans and care instructions you agreed to with your care team.
• I will respect the property of the health center, OCH staff, and other patients
• Abide by the policies of One Community Health
• Provide accurate and complete information about your present medical concerns, past medical history, and report any changes of your medical status to your provider
• Provide accurate and correct demographic and financial/insurance information
• Fulfill the financial obligations related to your treatment

Limited English Proficiency:

One Community Health is committed to provide equal opportunity in all services, programs, and activities to persons with limited English proficiency (LEP). Services include providing oral interpretation and written translation, free of cost to LEP patients. The purpose is to ensure patients with LEP receive meaningful, accurate, and equal access to information regarding all aspects of their care and services rendered.

If you have difficulty following these guidelines:

Your care team will work with you to develop a customized Patient Care Agreement so that you may be more successful. If there is further difficulty with the Patient Care Agreement or these guidelines, you may be discharged from care at One Community Health and will be provided alternative options for care. At any time, you may request to talk to the Clinic Site Director if you have concerns regarding One Community Health’s staff’s behavior or treatment.

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.”This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balance billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-877-696-6775.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

This is an agreement between One Community Health, as creditor, and the Patient/Debtor named.
In this agreement, the words “you,” “your,” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we,” “us,” and “our” refer to One Community Health.

Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month.

Payments: Unless other arrangements are approved by OCH in writing, payment in full will be due within 45 days after insurance resolution and becomes the patient’s responsibility.

Sliding Scale Discounts: OCH offers sliding scale discounts to low-income families who earn up to 200% of the Federal Poverty Guidelines. Sliding scale discounts are based on family size and income. As a federal grantee, we are obligated to request proof of income annually to determine eligibility for sliding scale discounts.

• OCH WILL EDUCATE PATIENTS ON APPLYING FOR THE SLIDING SCALE DISCOUNT AND POSSIBLE ENROLLMENT IN MEDICAID PRIOR TO AN APPOINTMENT. Sliding Fee Payments are due at the time of service.
• OCH has formal written contracts & referral arrangements for certain additional services that the health center does not provide i.e., labs, certain diagnostic imaging, etc. These arrangements have an equal or better slide than OCH in most cases. In cases where the slide is not better, the patient is not responsible for any amount greater than our sliding scale fee. If you have questions regarding our referral partners, please talk with a referral coordinator.

Suspension: OCH shall have the right to suspend scheduling privileges for unwillingness to pay.

Payment options if you have no insurance:

• If you have not completed a Sliding Fee discount application and do not have insurance, you will be expected to pay charges in full. Payment can be made by cash, check, or credit card.
• A minimum prepayment is required on certain medical and dental procedures including, but not limited to circumcision, root canals, and immigration physicals.
• Under some circumstances we will allow you to make special payment arrangements. We will ask you to sign a written payment plan agreement and make payments over a maximum 6-month period. If circumstances prevent your ability to do this, please reach out to a member of our billing staff that will work with you and your situation.

Payment options if you have insurance: You are responsible for co-pays, deductibles, and outstanding balances remaining after your insurance company has paid.

• It is your responsibility to provide all necessary insurance eligibility, identification, authorization, and referral information and to notify our office of any information changes when they occur. Even a preauthorization of services does not guarantee payment from your insurance carrier. It is the patient’s responsibility to know if our office is participating or non-participating with their insurance plan. Failure to provide all required information may necessitate patient payment for all charges. When insurance is involved, we are contractually obligated to collect co-payments, coinsurance, and deductibles, as outlined by your insurance carrier.
  • Please be aware that out-of-network insurance carriers often prohibit assignment of benefits and may try to limit their financial liability with arbitrary limits, exclusions, or reductions such as reasonable and customary or usual and prevailing reductions. If we are not contracted with your carrier, we will not negotiate reduced fees with your carrier.
• We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and plan limitations.
• Any balance outstanding will be due within 45 days of insurance resolution.

Returned checks: There is a fee (currently $25) for any checks returned by the bank.

Past due accounts: If your account becomes past due, we will take the necessary steps to collect this debt. If we must refer your account to a collection agency, you agree to pay all the collection costs which are incurred. If we must refer collection of the balance to a lawyer, you agree to pay all lawyers’ fees which we incur plus all court costs. In case of suit, you agree the venue shall be in Hood River County, Oregon.

Waiver of confidentiality: You understand if this account is submitted to an attorney or collection agency, if we must litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

Personal Injury: If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney prior to your initial visit. In addition to this verification, we require that you allow us to bill your health insurance. In the absence of insurance, other financial arrangements may be discussed. Payment of the bill remains the patient’s responsibility. We cannot bill your attorney for charges incurred due to a personal injury case.

Effective Date: Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This Notice of Privacy Practices applies to One Community Health.
Please review it carefully.

Protected health information (“PHI”) is health information that could identify you. This includes information such as your name, address, phone number, date of birth, information collected and recorded in this office, as well as information received from other health care providers. PHI may be in written, electronic, or spoken form. PHI may include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity, and similar types of health-related information.

Our Responsibilities

• We are required by law to maintain the privacy and security of your PHI.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your PHI.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your PHI 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.

One Community Health is part of an organized health care arrangement including participants in OCHIN. A current list of OCHIN participants is available at www.ochin.org as a business associate of One Community Health OCHIN supplies information technology and related services to One Community Health and other OCHIN participants. OCHIN also engages in quality assessment and improvement activities on behalf of its participants. For example, OCHIN coordinates clinical review activities on behalf of participating organizations to establish best practice standards and assess clinical benefits that may be derived from the use of electronic health record systems. OCHIN also helps participants work collaboratively to improve the management of internal and external patient referrals. Your personal health information may be shared by One Community Health with other OCHIN participants or a health information exchange only when necessary for medical treatment or for the health care operations purposes of the organized health care arrangement. Health care operations can include, among other things, geocoding your residence location to improve the clinical benefits you receive.

The personal health information may include past, present, and future medical information as well as information outlined in the Privacy Rules. The information, to the extent disclosed, will be disclosed consistent with the Privacy Rules or any other applicable law as amended from time to time. You have the right to change your mind and withdraw this consent, however, the information may have already been provided as allowed by you. This consent will remain in effect until revoked by you in writing. If requested, you will be provided a list of entities to which your information has been disclosed.

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all PHI we have about you. The new notice will be available upon request in our office and on our website.

Our Uses and Disclosures

We may use or share your PHI, without obtaining your permission, in the following ways:

Treat you             

We can use your PHI and share it with other professionals who are treating you.

Example: Your health care provider may ask another provider about care you have received in the past to help treat you.

Run our organization

We can use and share your PHI to run our organization, improve your care, and contact you when necessary.

Example: We use your PHI to manage your treatment and services.

Bill for your services

We can use and share your PHI to bill and get payment from health plans or other entities. 

Example: We share PHI about care provided to you with your health insurance plan so it will pay for your services.

How else can we use or share your PHI?

We may use and share your PHI without asking your permission in certain circumstances outlined below:

Public health and safety issues

We can use and share your PHI in certain situations such as for:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Research

We can use or share your PHI for health research, if certain requirements are met.

Compliance

We can use or share your PHI with health oversight agencies for activities authorized by law, such as audits and investigations, or as we are otherwise legally required.

Organ and tissue donation

We can share your PHI with procurement organizations.

Medical examiner or funeral director

We can share your PHI with a coroner, medical examiner, or funeral director if you die.

Workers’ compensation

We can use or share your PHI with employers, insurers, and others to comply with workers’ compensation and employment safety laws.

Law enforcement

• We can share your PHI with law enforcement in limited circumstances, such as:
• To report a crime that occurs in One Community Health facilities
• To assist with identifying or locating a suspect, fugitive, material witness, or missing person (but only certain PHI may be shared)
• To make legally-required reports, such as for gunshots or stab wounds
• To report suspected abuse, neglect, or domestic violence
• To prevent or reduce a serious threat to anyone’s health or safety

Other government requests

Lawsuits and legal actions

• We can use and share your PHI for special government functions such as military, national security, and presidential protective services.
• We can use and share your PHI to respond to a court or administrative order, warrant, or subpoena.

When it comes to your PHI, you have certain rights.

If you would like to exercise any of the rights described below, you must do so by submitting your request in writing to the One Community Health Privacy Officer using the information at the bottom of this page. In some cases, we may charge you a reasonable cost-based fee for providing materials to you.

Get an electronic or paper copy of your health records

• You can ask to see or get an electronic or paper copy of your health records and other PHI that we use to make decisions about you.
• In certain circumstances, we may say “no” to your request, but we’ll tell you why and you may ask that this decision be reviewed. Ask us how to do this.
• We will provide a copy or a summary of the PHI we use to make decisions about you, usually within 30 days of your request.

Ask us to correct your health records

• You can ask us to correct PHI we use to make decisions about you that you think is incorrect or incomplete.
• In certain circumstances, we may say “no” to your request, but we’ll tell you why and you may ask that this decision be reviewed.

Request confidential communications

• 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.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain PHI for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out of pocket in full, you can ask us not to share PHI related to that service or item for the purpose of payment or our operations with your health insurer.
• We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared PHI

You can ask for a list (accounting) of the times we’ve shared your PHI with third parties for reasons other than treatment, payment, health care operations, and certain other circumstances in the six years prior to your request.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.

Choose someone to act for you

If you have given someone power of attorney for health care or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting the One Community Health Privacy Officer using the information at the end of this page.
• 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/.
• We will not retaliate against you for filing a complaint.

Your Choices – For certain PHI, you have choices about what we share.

You may tell us to:

• Share your PHI with your family, close friends, or others involved in your care
• Share your PHI in a disaster relief situation

If you are not able to consent or object to our sharing your PHI (for example, because you are unconscious), we may share your PHI if we believe it is in your best interest.

Without your written permission, we may not:

• Share your PHI for marketing purposes
• Sell your PHI
• Share any psychotherapy notes

Sensitive Information:

Federal and state laws impose special protections for certain kinds of PHI and require us to obtain your permission before we can share it unless special circumstances apply. For example, psychotherapy notes, genetic testing information, HIV/AIDS test results, behavioral health, and substance abuse-related information may be specially protected. Before sharing these types of information, we will contact you for your permission, if necessary.

Fundraising:

We may use your PHI to contact you for fundraising efforts, but you can tell us not to contact you again.