Fill - Free fillable Patient Registration Form PDF form

Patient Registration Form

SF820 Clinicas del Camino Real, Inc. (06/2020) Page 1

Patient Information

Last Name:

First Name:

Middle:

Nickname:

Social Security Number:

Date of Birth: / /

Demographics

Home Address: Apt/Space #

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Marital Status: Single Married Divorced Legally Separated Widowed Interlocutory Domestic Partner Life Partner

Preferred Language:

English Spanish Mixteco

Other:___________

Home Phone Number:

Cell Phone Number:

Email Address:

Primary Care Provider:

Person Responsible (Must be an adult over 18 years old)

Last:

First Name:

Middle:

Social Security Number:

Relation to Patient:

Home Address:

City:

State:

Zip:

Home Phone Number:

Cell Phone Number:

Email Address:

Parent/Legal Guardian Information (if the patient is younger than 18 years of age)

Father’s Name

Father’s Date of Birth:

Father’s Cell Phone Number:

Mother’s Name

Mother’s Date of Birth

Mother’s Cell Phone Number:

Insurance Information (Please present your insurance card)

Type(s) of Health Care Coverage: Private Insurance Medi-Cal Medicare None Other: _____________________________________

Primary:

ID #:

Group #:

Policy Holder Name:

Relationship to Patient: Self Spouse Parent

Date of Birth:

Social Security Number

Secondary:

ID #:

Group #:

Policy Holder Name:

Relationship to Patient: Self Spouse Parent

Date of Birth:

Social Security Number

Sexual Orientation (Please answer the following questions in order for us to better serve you.)

Birth Sex:

Male Female

Undifferentiated Unknown

Gender Identity:

Male Female

Male to Female (MTF)/Trans Female/Trans Woman Female to Male (FTM)/Trans Male/Trans Man

Choose not to disclose

Additional gender category or other, please specify: ____________________________________________

Sexual Orientation:

Choose not to disclose Heterosexual

Bisexual Lesbian, Gay, Homosexual

Something else Don’t know

Preferred Pronoun:

Asked but unknown She, Her, Hers Ze/Hir

Decline to Answer They, Them, Theirs

He, Him, His Other: __________________________

Date of Birth: / /

Patient Registration Form

SF820 Clinicas del Camino Real, Inc. (06/2020) Page 2

Homeless Status (Please answer the following questions in order for us to better serve you.)

1. Please select one of the below options:

Not Homeless Street Shelter Hotel

Doubling up (Living with Friends/Family) Transitional (Group Home) Unreported

2. Are you living in Public Housing? Yes No

Agricultural Status (Please answer the following questions in order for us to better serve you.)

1. In the last 2 yrs., have you or anyone in your family, worked in any type of agriculture (farm work) like: planting, picking,

Preparing the soil, packing house, driving a truck for any type of farm work, worked with animals like cows, chickens, etc.? Yes No

2. In the last 2 yrs., have you or anyone in your family established a temporary home in order to work in any type of agriculture (farm work)? Yes No

3. Have you or a member of your family stopped migrating to work in agriculture (farm work) because of a disability or age? Yes No

Race/Ethnicity

Race (Mark all that are applicable):

American Indian/ Alaskan Native Native Hawaiian

Asian Other Pacific Islander

Black/African American White

More than one race Unreported/Refused to Report

Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

Unknown/ Not Reported

Veteran Status

1. Are you a U.S. Veteran? Yes No

Family Income (For Reporting Purposes Only)

Family Size: __0 __1 __2 __3 __4 __5 __6 __7 __8 __9 __10

Estimated Annual Household Income: $________________

Pharmacy Information

Primary Pharmacy

Pharmacy Name: ________________________________________

Address: _______________________________________________

City:___________________ State: ______ Zip Code:________

Phone Number:___________________________

Fax Number: _____________________________

Secondary Pharmacy (if applicable):

Pharmacy Name: ________________________________________

Address: _______________________________________________

City:___________________ State: _______ Zip Code:_______

Phone Number:___________________________

Fax Number: _____________________________

Emergency Contact

How Did You Hear About Us?

Please mark one of the following

Friend/Family Member Mailed Advertisement

Website/ Internet Insurance Referral

Newspaper Physician Referral (list name):_________________________

Yellow Pages Other (please specify):________________________

Radio

I hereby consent to any necessary medical or surgical treatment, which may include prescribed medications issued by the provider. I understand that even

simple treatments or diagnostic measures have a risk of complications. In such cases, further consultation with the provider may be necessary. Clinicas Del

Camino Real, Inc. will make referrals for specialized services we are unable to provide here.

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I understand that I am financially responsible for all

charges, whether covered or paid by said insurance. Should Clinicas Del Camino Real, Inc. participate with my insurance plan all co-payments and

co-insurance payments are due at the time services are rendered. I hereby assign to Clinicas Del Camino Real, Inc. all insurance benefits to which I am

(or my child is) entitled, including but not limited to Medicare, Private Health Insurance, and any other form of coverage paying benefits. I hereby authorize

Clinicas Del Camino Real, Inc. to release all necessary information to secure payment.

Date: Name (Print): Signature: __________

Phone Number (different from primary contact number(s) stated on reverse):

Relationship to Patient:_____________________________

Emergency Contact Name:__________________________________

HEALTH HISTORY/HISTORIA DE SALUD

Patient Name/Nombre:________________________________ Id:___________ DOB/Fecha de Nacimiento:________________ Gender/Sexo:_________

MEDICAL HISTORY/HISTORIA MÉDIC

Yes/Sí No

1. Are you currently under the care of a physician/Esta bajo el cuidado de un médico

Physician/Medico: Office Phone/Teléfono:

Condition/Condición:

. Are you taking any medication(s)/Está tomando medicamento(s)? If yes, what medication(s)/Nombres de medicamento(s)

. Have you had surgery or x-ray treatment for a tumor, growth, or other condition of your mouth or lips?

Ha tenido cirugía o tratamiento de rayos x para algún tumor, crecimiento o condición de la boca o labios? Date/Fecha

. Do you smoke/Fuma

5. Do you drink alcohol/Toma alcohol

. Do you use any illicit drugs(amphetamine, cocaine,etc)/Usa drogas ilícitas (anfetamina/cocaína, etc.)

. Are you allergic to or have you reacted adversely to any of the following/Tiene alergia o a tenido una reacción adversa a alguno de los siguientes?

Local Anesthetics/Anestesia Local Penicillin/Penicilina Iodine/Yodo Sulfa drugs/Medicamentos con Sulfa AspirAspirin/Aspirina

Codeine or other narcotics/Codeina o narcóticos Latex/Rubber/Goma

Other/Otro:

. Do you have a prosthetic joints or metal inserts/Tiene prótesis de hueso o insertos de metal?

Hip Joint Prosthesis Implants Breast Implants Bone Plates Screws Date/Fecha:

. Have you had any history of Oral Cancer/Tiene antecedentes de Cáncer Oral

10. Have you ever had any other type of Cancer/Tiene antecedentes de algún otro tipo de cáncer

11. Are you pregnant/Esta embarazada

Estimated delivery date/Fecha estimada de parto:

12. Are you nursing/Está dando pecho (amamantando)

13. Do

ou have or have

ou had an

of the followin

/Tiene o ha tenido al

uno de los si

uientes condiciones médicas

Yes/Sí No Yes/Sí No Yes/Sí No

. Heart conditions/Problemas del Corazó

H. Organ Transplant/Trasplante de órgan

. HyO. Hyper/Hypo thyroi

ertiroidismo o hi

otiroidism

B. Heart Murmur/Soplo del Corazó

I. Stroke/Derrame cerebral

Date/Fecha:

R. Arthritis/Artriti

C. Heart Attack/Ataque del Corazón

Date/Fecha:

J. Asthma/Asm

. HIV/AIDS/VIH o Sid

SF247 4/24/12

D. High Blood Pressure/Alta presió

K. Seasonal Allergy/Alergia temporal

. Stomach ulcers/Ulceras en el estomag

1. Pain in chest upon exertion

Dolor en el pecho cuando hace esfuerz

L. Fainting spells or seizures-Epilepsy

Desmayos o convulsiones

U. Kidney trouble/Problemas del riñó

2. Cardiac pacemaker/Marca pasos cardiaco

M. Diabetes (TypeI or II)/(Tipo I o II)

. Tuberculosi

E. Sinus trouble/Problemas de sinusiti

N. HeM. Hepatitis, jaudice or liver disease

Hepatitis, ictericia, o problemas del hígado

. Venereal disease/Enfermedad venére

F. Steroid Therapy/Terapia de esteroide

O. Anemi

. Psychiatric Care/Cuidado psiquiátric

G. Hives or skin rash/Ronchas o salpullid

P. Inflammaotry reheumatism(painfull, swollen,joints)

Inflamación reumática(coyunturas inflamables)

DDS COMMENTS/Nota del dentista

SA I II III IV

Medical Clearance Request/Necesita Autorización Medic

Yes/Sí No

DENTAL HISTORY/HISTORIAL DENTAL

Yes/Sí No

Date/Fecha

Dentist Name: Office Phone/Teléfono:

1. Have

ou seen a dentist within the

ast

ear outside of Clinicas

. When was your last x-ray?

Don't Know Date:

. Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?

Ha sufrido de sangrado anormal asociado con alguna extracción previa, cirugía dental o trauma

. How many times do you brush your teeth each day/Cuantas veces se lava los dientes cada día

Once/Una vez Twice/Dos veces Three times/Tres veces

5. Do you use dental floss/Usa hilo dental

. Do your gums bleed or hurt/Le sangran o le duelen las encías

. Are any of your teeth sensitive to/Siente sensibilidad a lo

Hot/Caliente Cold/Frio Sweet/Dulce Pressure/Presión

. Does food get caught in your teeth/Retiene comida en sus dientes

. Do you clench or grind your teeth/Aprieta o rechina sus dientes

10. Have you experienced any pain or soreness in the muscles of your face or around your ear?

Ha tenido algún dolor en los músculos de la cara o alrededor de los oídos

11. Does your jaw click or pop/Suena o cruje su quijada

SF247 4/24/12

1/9/2018

Dental Appointment Policy

Dear Patient:

When you make an appointment with your Dentist, the time is reserved exclusively for you. If

you fail to show up, the appointment time is lost. Clinicas del Camino Real, Incorporated has a

Dental Appointment Policy in an effort to ensure access for all our dental patients. This includes

the following:

1. Twenty four (24) to forty eight (48) hours before your appointment time, you MUST

confirm that you will attend. You will be expected to speak directly with a Clinicas

representative unless the health center where your appointment is scheduled offers

appointment confirmation through automated phone message, text message or email. If

these alternative appointment confirmation methods are available, you will not be

expected to speak directly to a Clinicas representative.

2. You must cancel or reschedule your dental appointment at least 24 hours in advance.

Without a 24 hour notice, the appointment is considered a failed appointment.

3. If you are late, your appointment may be cancelled and/or rescheduled for another day.

If the dentist’s schedule allows, you may wait to be seen as a “walk-in” (patient without

an appointment).

IMPORTANT:

Due to the large number of patients waiting for a dental appointment, if you fail to

confirm that you will be attending your appointment, your reserved appointment time will

be given to another patient. At that time, you will have the following options: (1) be seen

as a walk-in (if time dentist’s schedule allows) or (2) reschedule your appointment and be

placed on a waiting list and be contacted in the event that a sooner appointment

becomes available. If you fail to confirm and miss your scheduled appointment more

than twice in a year, you will only have the option to be seen in a walk-in basis for the

remainder of the year.

Your signature confirms that you have read and understand this policy.

____________________________ ____________________________ _________________

Signature Relation to patient Date

(If minor, parent signature)

Patient Name: _____________________________

MR #: ________________

Patient’s Learning Needs Assessment

Patient’s Name: Date:

We would like to know about your learning preferences so we can make sure we are

meeting your needs. Your responses are directly responsible for improving these services.

Thank you for your time.

1. Circle highest year of school completed:

N/A None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+

(Primary) (High School) (College / University)

2. What language do you prefer to speak?

 English  Spanish  Other:

3. What language do you prefer to read?

 English  Spanish  Other:

4. Which of the following best describes how you read:

 Like to read & read often  Can read but do not read often

 Do not like to read  Do not know how to read

5. How do you prefer to learn new things? (check all that apply)

 Reading (pamphlets, books)  Listening to audio tapes

 Practicing new skills following a demonstration  Viewing films / videos

 Attending individual education sessions  Attending group classes

 Using instructional illustrations, posters, pictures, flip charts

 Other:

6. Do you have any mental, emotional, or physical conditions that may affect the way

you learn?

 No  Yes

SF416 /kc

Patient’s Name Chart #

(Nombre del Paciente) (Numero de Expediente)

Acknowledgement of Receipt of Clinicas Del Camino Real, Inc.’s

Privacy Practices Notice, Advance HealthCare Directives information and

Patient Portal Instructions.

I, have received

a copy of Clinicas Del Camino Real, Inc. Privacy Practices Notice, Advance

HealthCare Directives information, and Patient Portal Instructions.

Signature Date

Reconocimiento de Recibo de Aviso de las Prácticas de Privacidad

de Clínicas del Camino Real, Inc., Directiva Anticipada de Atención

de la Salud, e Instrucciones del Portal del Paciente.

Yo, reconozco que he recibido

una copia del Aviso de las Practicas de Privacidad de Clinicas del Camino Real, Inc.,

información sobre Directiva Anticipada Atención de la Salud, e Instrucciones del Portal

del Paciente.

Firma Fecha

Rev. 9/11/2020 – SF100

Staff Use Only/Para Uso de Oficina Solamente:

If the Privacy Practices Notice, Patient Portal Instructions, and Advance HealthCare Directives information was

not given to the patient or the patient’s legal representative, please indicate the reason why below:

Right to Amend

If you believe health and/or claims record

information we have about you is incorrect or incomplete, you

may ask us to amend the information. You have the right to

request an amendment as long as the information is kept by this

office.

To request an amendment, complete and submit a Medical

Record Amendment/Correction Form to the clinic's Privacy

Officer. We may deny your request for an amendment if it is not

in writing or does not include a reason to support the request. In

addition, we may deny your request if you ask us to amend

information that:

a) We did not create, unless the person or entity that created

the information is no longer available to make the

amendment.

b) Is not part of the health information that we keep.

c) You would not be permitted to inspect and copy.

d) Is accurate and complete.

If your request is denied, we will send you the reason why in

writing within 60 days.

Right to Choose Someone to Act for You

You have the right

to choose someone to act for you. If you have given someone

medical power of attorney or if someone is your legal guardian,

that person may exercise your rights and make choices about

your health information. We will make sure the person has this

authority and can act for you before any action is taken.

You can change or cancel your request for someone to act for

you as long as you can communicate your wishes.

To change the person you want to make your healthcare

decisions, you must sign a statement or tell the doctor in charge

of your care.

Right to an Accounting of Disclosures

You have the right to

request an "accounting of disclosures" This is a list of the

disclosures we made of medical information about you for

purposes other than treatment, payment and health care

operations. To obtain this list, you must submit your request in

writing to the Privacy Officer. It must state a time period, which

may not be longer than six years and may not include dates

before April 14, 2003. Effective January 1, 2011, you have the

right to receive an accounting of all disclosures made from

Electronic Health Records (EHR) during the three years prior to

the request. Your request should indicate in what form you want

the list (for example, on paper, electronically). We may charge

you for the costs of providing the list. We will notify you of the

cost involved and you may choose to withdraw or modify your

request at that time before any costs are incurred.

Right to Request Restrictions

You have the right to request a

restriction or limitation on the health information we use or

disclose about you for treatment, payment or health care

operations. You also have the right to request a limit on the health

information we disclose about you to someone who is involved in

your care or the payment for it, like a family member or friend. For

example, you could ask that we not use or disclose information

about a surgery you had.

We are Not Required to Agree to Your Request

If we do agree,

we will comply with your request unless the information is needed

to provide you emergency treatment.

To request restrictions, you may complete and submit the Request

for Restriction on Use/Disclosure of Medical Information to the

Privacy Officer.

Right to Request Confidential Communications

You have the

right to request that we communicate with you about medical

matters in a certain way or at a certain location. For example, you

can ask that we only contact you at work or by mail.

To request confidential communications, you may complete and

submit the Request for Restriction on Use/Disclosure of Medical

Information and/or Confidential Communication to Privacy Officer.

We will not ask you the reason for your request. We will

accommodate all reasonable

requests. Your

request must specify

how or where you wish to be contacted.

Disaster Relief Situation

You have the right and choice to tell

us how to share your information during a disaster relief situation.

You can tell us what you want us to do, and we will follow your

instructions.

Right to a Paper Copy of This Notice

You have the right to a

paper copy of this notice. You may ask us to give you a copy of

this notice at any time. Even if you have agreed to receive it

electronically, you are still entitled to a paper copy. To obtain such

a copy, Contact the Privacy Officer.

CHANGES TO THIS NOTICE

We reserve the right to change this notice, and to make the

revised or changed notice effective for medical information we

already have about you as well as any information we receive in

the future. We will post a summary of the current notice in the

office with its effective date in the bottom

right hand

corner. You

are entitled to a copy of the notice currently in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may

file a complaint with our office or with the Secretary of the

Department of Health and Human Services. To file a complaint

with our office, contact your nearest Clinicas del Camino Real,

Inc. location and ask to speak to the Privacy Officer. You will not

be penalized for filing a complaint.

Clinicas del Camino Real, Inc. EI Rio

221 Ventura Blvd. Suite 126, Oxnard, CA 93036

(805) 436-3444

Clinicas del Camino Real, Inc., Fillmore

355 Central Ave., Fillmore, CA 93015

(805) 524-4926

Clinicas del Camino Real, Inc., Maravilla

450 W. Clara St., Oxnard, CA 93031

(805) 488-0210

Clinicas del Camino Real, Inc., Newbury Park

1000 Newbury Rd. Suite 150, Newbury Park, CA 91320

(805) 498-3640

Clinicas del Camino Real, Inc., North Oxnard

1200 N. Ventura Rd. Suite E, Oxnard, CA 93030

(805) 988-0053

Clinicas del Camino Real, Inc., Ocean View

4400 Olds Road, Oxnard, CA 93033

(805) 986-5551

Ojai Valley Community Health Center

1200 Maricopa Highway, Ojai, CA 93023

(805) 640-8293

Clinicas del Camino Real, Inc., Oxnard

650 Meta Street, Oxnard, CA 93030

(805) 487-5351

Clinicas del Camino Real, Inc., Santa Paula

500 E. Main Street, Santa Paula, CA 93060

(805) 933-0895

Clinicas del Camino Real, Inc., Ventura

200 S. Wells Rd. Suite 100, Ventura, CA 93004

(805) 647-6322

Clinicas del Camino Real, Inc. Corporate Office

200 S. Wells Rd.

Suite 200, Ventura, CA 93004

(805) 659-1740

Clinicas del Camino Real, Inc., Simi - Madera

1424 Madera Rd., Simi Valley, CA 93065

(805) 522-5722

Clinicas del Camino Real, Inc., Moorpark

4279 Tierra Rejada, Moorpark, CA 93021

(805) 222-2323

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH

INFORMATION ABOUT YOU MAY BE

USED AND DISCLOSED AND HOW YOU

CAN GET ACCESS TO THIS

INFORMATION.

Clinicas del Camino Real, Inc. is committed to providing quality

healthcare services to you. An important part of that is protecting

your medical information according to applicable law. This notice

describes your rights and duties under Federal Law, as well as

other pertinent information.

This notice describes the information privacy practices that are

followed by our employees, staff and other office personnel.

This notice applies to the information and records we have about

your health, health status, and the health care services you

receive at this office.

We are required by law to give you this notice. It tells you about

the ways in which we may use and disclose health information

about you and describes your rights and our obligations regarding

the use and disclosure of that information.

If you have any questions about this notice, please ask to speak to

the Privacy Officer at this or any Clinicas del Camino Real, Inc.

locations.

HOW WE MAY USE AND DISCLOSE

HEALTH INFORMATION ABOUT YOU

For Treatment We may use health information about you to

provide you with medical treatment or services. We may

disclose health information about you to doctors, nurses,

technicians, office staff, or other personnel who are involved in

taking care of you and your health.

For example, your doctor may be treating you for a heart

condition and may need to know if you have other health

problems that could complicate your treatment. The doctor may

use your medical history to decide what treatment is best for

you. The doctor may also tell another doctor about your

condition so that doctor can help determine the most

appropriate care for you. You may revoke your Consent at any

time by giving us written notice.

SF901-E (11/2013)

Different personnel in our office may share information about

you for insurance coverage options and disclose information to

people who do not work in our office in order to coordinate your

care, such as phoning in prescriptions to your pharmacy,

scheduling lab work and ordering x-rays. Family members and

other health care providers may be part of your medical care

outside this office and may require information about you that we

have.

For Payment

We may use and disclose health information

about you so that the treatment and services you receive at this

office may be billed to and payment may be collected from you,

an insurance company or a third party. For example, we may

need to give your health plan information about a service you

received here so your health plan will pay us or reimburse you

for the service. We may also tell your health plan about a

treatment you are going to receive to obtain prior approval, or to

determine whether your plan will cover the treatment.

For Health Care Operations We may use and disclose health

information about you in order to run the office and make sure

that you and our other patients receive quality care. For

example, we may use your health information to evaluate the

performance of our staff in caring for you. We may also use

health information about all or many of our patients to help us

decide what additional services we should offer, how we can

become more efficient, or whether certain new treatments are

effective.

Business Associate

We may use or disclose your health

information to a business associate that performs a business

function on our behalf and requires your health information in

order to do so. Such use or disclosure will only occur after

performing due diligence to ensure that the business associate

is meeting all statutory and contractual requirements. A written

contract will be executed with each business associate, and will

be reviewed on a yearly basis, to ensure that the business

associate is providing adequate protected health information

safeguards.

Appointment Reminders

We may contact you as a reminder

that you have an appointment for treatment or medical care at

the office.

Treatment Alternatives

We may tell you about or recommend

possible treatment options or alternatives that may be of interest

to you.

Health-Related Products and Services We may tell you about

health-related products or services that may be of interest to

you.

Please notify us if you do not wish to be contacted for

appointment reminders, or if you do not wish to receive notices

about treatment alternatives or health-related services. If you

advise us in writing (at the address listed on this Notice) that you

do not wish to receive such communications, we will not use or

disclose your information for these purposes.

Your revocation will be effective when we receive it, but it will not

apply to any uses and disclosures which occurred before that

time. If you do revoke your Consent, we will not be permitted to

use or disclose information for purposes of treatment, payment or

health care operations, and we may therefore choose to

discontinue providing you with health care treatment and services.

SPECIAL SITUATIONS

We may use or disclose health

information about you without your permission for the

following purposes, subject to all applicable legal

requirements and limitations:

To Avert a Serious Threat to Health or Safety

We may use and

disclose health Information 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.

Required By Law

We will disclose health information about you

when required to do so by federal, state or local law.

Research We may use and disclose health information about you

for research projects that are subject to a special approval

process. We will ask you for your permission if the researcher will

have access to your name, address or other information that

reveals who you are.

Organ and Tissue Donation If you are an organ donor, we may

release health information to organizations that handle organ

procurement or organ, eye or tissue transplantation or to an organ

donation bank, as necessary to

facilitate

such

donation and

transplantation.

Military. Veterans. National Security and Intelligence If you are

or were a member of the armed forces, or part of the national

security or intelligence communities, we may be required by

military command or other government authorities to release

health information about you. We may also release information

about foreign military personnel to the appropriate foreign military

authority.

Workers' Compensation

We may release health information

about you for workers' compensation or similar programs. These

programs provide benefits for work-related injuries or illness

Law Enforcement

We may release health information if asked to

do so by a law enforcement official in response to a court order,

subpoena, warrant, summons or similar process, subject to all

applicable legal requirements.

Public Health Risks

We may disclose health information about

you for public health reasons in order to prevent or control

disease, injury or disability; or report births, deaths, suspected

abuse or neglect, non-accidental physical injuries, reactions to

medications or problems with products.

Health Oversight Activities

We may disclose health information

to a health oversight agency for audits, investigations,

inspections, or licensing purposes. These disclosures may be

necessary for certain state and federal agencies to monitor the

health care system, government programs, and compliance with

civil rights laws.

Lawsuits and Disputes

If you are involved in a lawsuit

or a

dispute, we may disclose health information about you in

response to a court or administrative order. Subject to all

applicable legal requirements, we may also disclose health

information about you in response to a subpoena.

Coroners, Medical Examiners and Funeral Directors We may

release health information to a coroner or medical examiner. This

may be necessary, for example, to identify a deceased person or

determine the cause of death.

Information Not Personally Identifiable We may use or

disclose health information about you in a way that does not

personally identify you or reveal who you are.

Family and Friends

We may disclose health Information about

you to your family members or friends if we obtain your verbal

agreement to do so or if we give you an opportunity to object to

such a disclosure and you do not raise an objection. We may also

disclose health information to your family or friends if we can infer

from the circumstances, based on our professional judgment that

you would not object.

For example, we may assume you agree to our disclosure of your

personal health information to your spouse when you bring your

spouse with you into the exam room during treatment or while

treatment is discussed.

In situations where you are not capable of giving consent

(because you are not present or due to your incapacity or medical

emergency), we may, using our professional judgment, determine

that a disclosure to your family member or friend is in your best

interest. In that situation, we will disclose only health information

relevant to the person's involvement in your care.

We may also use our professional judgment and experience to

make reasonable inferences that it is in your best interest to allow

another person to act on your behalf to pick up, for example, filled

prescriptions, medical supplies, or X-rays.

OTHER USES AND DISCLOSURES OF

HEALTH INFORMATION

We will not use or disclose your health information for any

purpose other than those identified in the previous sections

without your specific, written Authorization. We must obtain

your Authorization separate from any Consent may have

obtained from you. If you give us Authorization to use or

disclose health information about you, you may revoke that

Authorization, in writing, at any time. If you revoke your

Authorization, we will no longer use or disclose information

about you for the reasons covered by your written

Authorization, but we cannot take back any uses or disclosures

already made with your permission.

We will not use your name and location in any facility directory,

as no facility directory exists.

If we have HIV or substance abuse information about you, we

cannot release that information without a special signed, written

authorization (different than the Authorization and Consent

mentioned above) from you. In order to disclose these types of

records for purposes of treatment, payment or health care

operations, we will have to have both your signed Consent and

a special written Authorization that complies with the law

governing HIV or substance abuse records.

YOUR RIGHTS REGARDING

HEALTH INFORMATION ABOUT YOU

Federal law provides you several important rights regarding

your health information. You have the following rights regarding

health information we maintain about you:

Right to Inspect and Copy

You have the right to inspect and

obtain a copy your health information, such as medical and

billing records, in the format you request, that we use to make

decisions about your care. You must submit a written request to

the Privacy Officer in order to inspect and/or copy your health

information. If you request a copy of the information, we may

charge a fee for the costs of copying, mailing or other

associated supplies. We may deny your request to inspect

and/or copy in certain limited circumstances. If you are denied

access to your health information, you may ask that the denial

be reviewed. If such a review is required by law, we will select a

licensed health care professional to review your request and

our denial. The person conducting the review will not be the

person who denied your request, and we will comply with the

outcome of the review.

This brochure explains your right

to make healthcare decisions and

how you can plan now for your

medical care if you are unable to

speak for yourself in the future.

A federal law requires us to give

you this information. We hope

this information will help increase

your control over your medical

treatment.

What happens when someone else makes

decisions about my treatment?

The same rules apply to anyone who makes

healthcare decisions on your behalf – a

healthcare agent, a surrogate whose name you

gave to your doctor, or a person appointed by

the court to make decisions for you. All are

required to follow your Health Care

Instructions or, if none, your general wishes

about treatment, including stopping treatment.

If your treatment wishes are not known, the

surrogate must try to determine what is in your

best interest.

The people providing your health care

must follow the decisions of your agent or

surrogate unless a requested treatment would

be bad medical practice or ineffective in

helping you. If this causes disagreement that

cannot be worked out, the provider must make

a reasonable effort to find another healthcare

provider to take over your treatment.

Will I still be treated if I don't make an

advance directive?

Absolutely. You will still get medical treatment.

We just want you to know that if you become

too sick to make decisions, someone else will

have to make them for you. Remember that:

• A Power of Attorney for Health Care lets

you name an agent to make decisions for you.

Your agent can make most medical decisions –

not just those about life sustaining treatments –

when you can't speak for yourself. You can

also let your agent make decisions earlier, if

you wish.

• You can create an Individual Healthcare

Instruction by writing down your wishes about

health care or by talking with your doctor and

asking the doctor to record your wishes in your

medical file. If you know when you would or

would not want certain types of treatment, an

Instruction provides a good way to make your

wishes clear to your doctor and anyone else

who may be involved in deciding about

treatment on your behalf.

How can I get more information about

making an advance directive?

Ask your doctor, nurse, social worker, or

healthcare provider to get more information for

you. You can have a lawyer write an advance

directive for you, or you can complete an

advance directive by filling in the blanks on a

form.

SF900-E

The right to choose your primary care

provider

As a patient of Clinicas del Camino Real, Incor-

porated (Clinicas) we will ensure that you have

access to quality health care that is appropriate

for your specific needs. You are guaranteed

the right to choose your Primary Care Provider

(PCP). In the event that you are not completely

satisfied with your active PCP within Clinicas

you have the right to request another PCP.

Your request will be reviewed and all feasible

attempts will be made to accommodate your

request.

Who decides about my treatment?

Your doctors will give you information and

advice about treatment. You have the right to

choose. You can say "Yes" to treatments you

want. You can say "No" to any treatment that

you don't want – even if the treatment might

keep you alive longer.

How do I know what I want?

Your doctor must tell you about your medical

condition and about what different treatments

and pain management alternatives can do for

you. Many treatments have "side effects."

Your doctor must offer you information about

problems that medical treatment is likely to

cause you.

Often, more than one treatment might

help you – and people have different ideas

about which is best. Your doctor can tell you

which treatments are available to you, but your

doctor can't choose for you. That choice is

yours to make and depends on what is

important to you.

Can other people help with my decisions?

Yes. Patients often turn to their relatives and

close friends for help in making medical

decisions. These people can help you think

about the choices you face. You can ask the

doctors and nurses to talk with your relatives

and friends. They can ask the doctors and

nurses questions for you.

Can I choose a relative or friend to make

healthcare decisions for me?

Yes. You may tell your doctor that you want

someone else to make healthcare decisions for

you. Ask the doctor to list that person as your

healthcare "surrogate" in your medical record.

The surrogate's control over your medical

decisions is effective only during treatment for

your current illness of injury or, if you are in a

medical facility, until you leave the facility.

What if I become too sick to make my own

healthcare decisions?

If you haven't named a surrogate, your doctor

will ask your closest available relative or friend

to help decide what is best for you. Most of the

time that works. But sometimes everyone

doesn't agree about what to do. That's why it is

helpful if you can say in advance what you

want to happen if you can't speak for yourself.

Do I have to wait until I am sick to express

my wishes about health care?

No. In fact, it is better to choose before you get

very sick or have to go into a hospital, nursing

home, or other healthcare facility. You can use

an Advance Health Care Directive to say who

you want to speak for you and what kind of

treatments you want. These documents are

called "advance" because you prepare one

before healthcare decisions need to be

made. They are called “directives” because

they state who will speak on your behalf and

what should be done.

In California, the part of an advance directive

you can use to appoint an agent to make

healthcare decisions is called a Power of

Attorney for Health Care. The part where you

can express what you want done is called an

Individual Health Care Instruction.

Who can make an advance directive?

You can if you are 18 years or older and are

capable of making your own medical decisions.

You do not need a lawyer.

Who can I name as my agent?

You can choose an adult relative or any other

person you trust to speak for you when medical

decisions must be made.

When does my agent begin making my

medical decisions?

Usually, a healthcare agent will make decisions

for you only after you lose the ability make

them yourself. But, if you wish, you can state in

the Power of Attorney for Health Care that

you want the agent to begin making decisions

immediately.

How does my agent know what I would

want?

After you choose your agent, talk to that person

about what you want. Sometimes treatment

decisions are hard to make, and it truly helps if

your agent knows what you want. You can also

write your wishes down in your advance

directive.

What if I don't want to name an agent?

You can still write out your wishes in your

advance directive, without naming an agent.

You can say that you want to have your life

continued as long as possible. Or you can say

that you would not want treatment to continue

your life. Also, you can express your wishes

about the use of pain relief or any other type of

medical treatment.

Even if you have not filled out a written

Individual Health Care Instruction, you can

discuss your wishes with your doctor, and ask

your doctor to list those wishes in your medical

record. Or you can discuss your wishes with

your family members or friends. But it will

probably be easier to follow your wishes if you

write them down.

What if I change my mind?

You can change or cancel your advance

directive as long as you can communicate your

wishes. To change the person you want to

make your healthcare decisions, you must sign

a statement or tell the doctor in charge of your

care.

Ambarella

Accessing Your Health Information Using the

CLINICAS PATIENT PORTAL

It only takes a moment to register for the Clinicas del Camino Real, Inc.

(Clinicas) patient portal. You will receive a PIN number via text

message and/or email. If you cannot locate your PIN, please call (805)

647-6353 to obtain another one.

How you enroll depends on whether you are a new user of the Clinicas

Patient Portal (either as a patient or a person authorized by a patient)

or have previously registered (either as a patient or a person authorized

by a patient).

 If you have NEVER registered to the Clinicas Patient Portal as

a patient or an authorized person for a patient, follow

instructions #

 If you have already enrolled in the Clinicas Patient Portal as a

patient or authorized person for a patient, follow instructions #

Follow if you are NEW to the Clinicas portal and are a PATIENT or

a PROXY (person authorized by patient to access their health

information)

• Access portal by one of the following options:

o Click on the link that was sent to you via text

message and/or email.

o Open a browser and go to

https://patientportal.clinicas.org

• If you connected using the website, click on “Create a New

Account”

• If you connected using the link sent to you via text or email

message, click “Let’s Get Started”

• Review the Terms & Conditions and scroll to the bottom of the

screen (Please note: The Terms & Conditions are in English,

followed by the Spanish version).

o Scroll to the bottom of the screen, check the box

next to “I verify I am at least 18 years of age”

o Click “I Accept”

• When asked if you have a pin, click “Yes”.

• Enter your PIN number and click “Next” (if you followed text or

email link, the PIN number will auto-populate)

• Read the Confirm Identity message and click “Next”

• Enter and confirm your email address and click “Next”

• Create a user name by following the on-screen instructions

and click “Next”

• Create a password by following the on-screen instructions

and click “Next”

• Choose a security question, provide an answer and click

“Next”.

• You’re all set!

o Take a “tour” (found on top right-hand corner under

your name) or go to the home page.

o Download the App for iOS or Android

Follow if you are ALREADY ENROLLED on the Clinicas

Patient Portal (as a patient or an authorized person for another

patient) and will also be an authorized person for the patient being

enrolled.

• Have the text message or email invite available including

the patient’s PIN number

• Open a browser and go to

https://patientportal.clinicas.org

• Enter your user name and password and click “Log In”

• Click on the down-arrow next to the patient name on the

top left-hand side of the screen.

• Click on “Connect With New Patient”

• Enter the patient’s PIN

• Read the Confirm Identity message and click “Next”

• Complete the Challenge Questions by entering the

patient’s first name, last name and date of birth. Click

“Next”

• Verify the patient’s demographic information and click

“Next”

• You’re all set! You can now view the patient’s health

information.

COMMUNICATE &

COLLABORATE

Communicate

securely with your

care teams to ask

and resolve

questions.

VIEW YOUR LAB

RESULTS

Access most of your

lab results as soon as

they are ready.

MEDICATION

REFILL REQUESTS

Medication refills are

as easy as a click of a

button.

CLINICAS PORTAL INSTRUCTIONS

Some exclusions apply for seeing lab results. Patients ages

12-17 will not have access to the portal.

FINANCIAL POLICY

MR#________________________

Thank you for choosing Clinicas del Camino Real, Inc. (CDCR) as your health care provider. We are committed to providing caring

and professional health care services to all of our patients. As part of the delivery of services, we have established a financial

policy which is designed to clarify payment policies of our practice. The person responsible for payment is required to read and

sign this form.

PAYMENT

Full payment is due at time of service. We accept cash, checks and credit cards (Visa, Mastercard, Discover, American Express).

There is a $50 fee for all returned checks. The adult accompanying a minor (or guardian of the minor) is responsible for full

payment.

SPECIAL PROGRAMS

You may be enrolled to special programs to assist in lowering cost of services. You will be responsible for payment for any non-

covered service.

INSURANCE

All patients must provide valid and up-to-date proof of insurance coverage. Please notify us of any changes in insurance

coverage prior to time of service.

We participate in most insurances but it is your responsibility to check if we are covered by your specific insurance plan. We will

bill your insurance as a courtesy service to you. The person responsible for payment of services will be sent a bill for any

remaining balance not paid by the insurance including services denied as not reasonable or necessary or not covered. Your

insurance policy is a contract between you and your insurance company so you will have to contact them to dispute any

payment denials.

USUAL AND CUSTOMARY RATES

We charge clients what is usual and customary for our area. You are responsible for payment regardless of your insurance

company’s arbitrary determination of usual and customary rates.

BALANCE POLICY

A balance statement will be mailed and payment in full is due upon receipt of this statement. Any balances 120 days past due

will be referred to a collection agency and/or credit bureau. The Agency will incur interest charges which will be payable to the

agency. In cases of divorce or separated parents, it will be the guarantor’s responsibility to pay any balances. Clinicas will not

participate in disputes between custodial or non-custodial parents.

APPOINTMENTS

Help us serve you better by keeping scheduled appointments. If you are unable to keep it, please contact us to reschedule at

least 24 hours before your appointment.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION AND ASSIGNMENT BENEFITS

I hereby authorize CDCR, Inc. to release any information necessary to my insurance carriers regarding my treatment and

condition that is necessary to determine plan benefits and to process payment for insurance claims. I authorize payment of

services directly to CDCR, otherwise payable to me.

I have read, understand and agree with the Financial Policy.

X______________________________________________ X_________________________________________________

PRINTED name of Person responsible for payment Signature of patient or Person responsible for payment & DATE

Revised: January 14, 2020

CONSENT TO RELEASE HEALTH INFORMATION TO INDIVIDUALS/FAMILY MEMBERS

The state of California mandates that health information be shared only with the patient or the

patient’s legal representative. In accordance with this law, every employee of Clinicas del

Camino Real, Inc. is required to sign a Confidentially Statement on an annual basis indicating

that they will keep the health information of every patient in the strictest confidence.

The staff and/ or physicians cannot release health information to family members of patients

without permission from the patient or the patient’s legal representative.

In order to authorize our providers and personnel to verbally release general health information

to individuals/family members, please list the name(s), phone number and relationship of those

individuals in the space provided below.

General information excludes the discussion of sexually transmitted diseases, HIV (AIDS Virus)

testing and/or results, pregnancy related services, drug and alcohol counseling, and psychiatric

/ mental health services.

Name:__________________________ Phone: _______________ Relationship:__________

 I do not authorize Clinicas del Camino Real, Inc. to release any information concerning my

health care to any individual.

I authorize Clinicas del Camino Real, Inc. to verbally release general health information to the

above named individual(s). This authorization will supersede any previous authorization(s) to

verbally release general health information.

___________________________________________ _____________________

Signature of patient or legally authorized individual Date

___________________________________________ _____________________

Witness Date

Patient Name: _____________________________

MR #: ________________

Revised 9/5/2019

ELECTRONIC COMMUNICATION CONSENT FORM

Clinicas del Camino Real, Inc. (Clinicas) is pleased to provide additional ways to communicate with its patients

by providing access to their medical records through the new Patient Portal and/or the Appointment

Confirmation System. We will need your consent in order to send you email or text message notifications

relating to the patient portal/appointment confirmation system. Please note that portal access and appointment

confirmation system is not available for patients ages 12-17.

For each section, please indicate whether you consent or decline:

PATIENT PORTAL (You will receive e-mail and/or text message notifications)

I consent to participate in Patient portal.

I decline to participate in Patient portal.

________ I want to grant access to the following person to have access to my patient portal.

First/Last Name:

Cell Phone:

( ) -

DOB:

Email:

Relationship:

APPOINTMENT CONFIRMATION SYSTEM (You’ll receive text message only)

I consent to participate in Appointment

Confirmation System.

I decline to participate in Appointment

Confirmation System.

I understand that I am responsible for informing Clinicas in writing of any changes in cell phone number and email

address. I understand that Clinicas del Camino Real, Inc. does not charge for this service, but standard text messaging

rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).

I understand that text and email messaging is not a secure format of communication. There is some risk that

individually identifiable health information or other sensitive or confidential information contained in such text/email

may be misdirected, disclosed to or intercepted by unauthorized third parties. Information included in text messages

may include your first name, date/time of appointments, name of physician, and physician phone number, or other

pertinent information.

_______________________________________________ _____________________

Patient/Guarantor Signature Date

For Office Use Only

(Patient Portal Proxy’s Only): Proxy name and information must be manually added in Staff Portal in order to send

a portal invite. Employee name and date confirms this task has been done.

____________________________________________ _____________________________

Staff Name Date

Patient Name: ________________________________

DOB: __________________ MR#: _____________

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