Welcome To Clinica! A Guide To Services, Hours and Important Information About Clinica

Transcription

1 Welcome To Clinica! A Guide To Services, Hours and Important Information About Clinica 2013

2 Introduction Page 2 Important Phone Numbers Medical Appointments Billing Questions Dental Appointments Financial Screening Appointments Pharmacy Refill Line Poison Control Center Emergency Assistance QuitLine QUIT-NOW Social Services Assistance Table of Contents Welcome To Clinica... Page 3 Locations & Hours of Operation... Page 4 Holidays When We Are Closed... Page 6 My Clinica... Page 7 Services We Offer... Page 9 Services We Don t Offer... Page 9 Your Rights and Responsibilities... Page 10 Pharmacy Services... Page 13 Dental Services... Page 14 Group Visits... Page 16 Behavioral Health Services... Page 16 Referrals To Specialty Care... Page 17 NextGen Patient Portal... Page 17 What Is A Medical Emergency?... Page 19 Making An Appointment... Page 21 When To Call Us... Page 22 Who To Call When We Are Closed... Page 22 Payment Programs at Clinica... Page 23 Billing Department... Page 24 Financial Screening... Page 25 Financial Screening Hours... Page 26 Your Comments Count... Page 27 Medical Records... Page 27 Your Health Records... Page 29

3 Welcome to Clinica! Since 1977, Clinica Family Health Services has provided health care to low-income, uninsured people living in southern Boulder, Broomfield and western Adams counties. We believe that everyone should have access to basic health care, no matter their ability to pay. We provide care to young and old, men and women, people with jobs and those without. Introduction Page 3 Our staff includes family physicians, pediatricians, obstetrician/ gynecologists, dentists, nurse practitioners, physician assistants, registered dieticians and behavioral health professionals. We have five medical and two dental clinics where we will care for you when you are sick, help you stay well and help you manage chronic problems. Additionally, our administration building has staff who can provide financial screening and answer questions about your bills. Here are some things that are important to us: We want to provide you with a patient centered medical home. We do this by building relationships between patients, their primary care providers and, when appropriate, the patient s family. We will do whatever we can to assure that you get the care you need, when you need it, in a manner that is comfortable for you. We believe that your mind affects your body, that what you eat matters and that preventing disease is better than any prescription. Our focus is on keeping you well. We do this by seeing you regularly, giving you immunizations and offering you health information. We want you to see the same team of health care providers at every visit. You will receive better, more affordable care this way. We want you to be involved in your own health care. We will help you set your own health goals and work towards them. We work in teams. Each team member has specific skills so we can provide most of your care at the clinic. All teams provide the same services, but each is a different color so you can tell them apart. Thank you for choosing Clinica as your health care provider. We look forward to working together to help you and your family live healthy lives.

4 Introduction Page 4 Our Locations & Hours Financial Screening 1345 Plaza Court North, 1A Lafayette, CO Administration Building Monday Opens 8am Lunch 1-2pm Closes 5pm Tuesday 8am 1-2pm 5pm Wednesday 8am 1-2pm 5pm Thursday 8am 1-2pm 5pm Friday 8am 1-2pm 5pm 8300 N. Alcott, #205 Westminster, CO Federal Heights Medical Clinic Monday Opens 8am Lunch 1-2pm Closes 5pm Tuesday 8am 1-2pm 8pm Wednesday 8am none 1pm Thursday 8am 1-2pm 5pm Friday 8am 1-2pm 5pm Pharmacy Outlet 2000 W. South Boulder Rd. Lafayette, CO Lafayette Medical Clinic Monday Opens 8:45am Lunch 1-2pm Closes 5:30pm Tuesday 8:45am 1-2pm 6:30pm Wednesday 8:45am 1-2pm 5:30pm Thursday 8:45am 1-2pm 6:30pm Friday 7:45am 1-2pm 4:30pm

5 Pharmacy & Financial Screening 1701 W. 72nd Ave. Denver, CO Pecos Medical & Dental Clinic Monday Opens 8am Lunch 1-2pm Closes 6pm Tuesday 8am 1-2pm 8pm Wednesday 8am 1-2pm 8pm Thursday 8am 1-2pm 8pm Friday 7:45am 1-2pm 5pm Introduction Page 5 Pharmacy & Financial Screening th Ave. Boulder, CO People s Medical Clinic Monday Opens 8am Lunch 1-2pm Closes 5pm Tuesday 8am 1-2pm 8pm Wednesday 8am 1-2pm 5pm Thursday 8am 1-2pm 8pm Friday 8am 1-2pm 5pm Pharmacy Outlet 8990 N. Washington St. Thornton, CO Thornton Medical & Dental Clinic Monday Opens 8am Lunch 1-2pm Closes 5pm Tuesday 8am 1-2pm 8pm Wednesday 8am 1-2pm 8pm Thursday 8am 1-2pm 8pm Friday 8am 1-2pm 5pm

6 Introduction Page 6 For Call Center hours see page 22 For Financial Screening hours see page 26 For Pharmacy hours see page 13 Holidays When We Are Closed New Year s Day (January 1) Martin Luther King, Jr., Day (third Monday of January) Memorial Day (last Monday of May) Independence Day (July 4) Labor Day (first Monday of September) Thanksgiving Day (fourth Thursday of November) Day After Thanksgiving (fourth Friday of November) Christmas Break (December 24 and December 25)

7 My Clinica My Primary Care Provider (PCP): My Care Team s Color: My Primary Dental Provider: My Clinic: FAMILY MEMBERS Introduction Page 7 My Spouse s PCP: His/Her Care Team s Color: His/Her Primary Dental Provider: His/Her Clinic: Child #1 s PCP: His/Her Care Team s Color: His/Her Primary Dental Provider: His/Her Clinic: Child #2 s PCP: His/Her Care Team s Color: His/Her Primary Dental Provider: His/Her Clinic: Child #3 s PCP: His/Her Care Team s Color: His/Her Primary Dental Provider: His/Her Clinic: Child #4 s PCP: His/Her Care Team s Color: His/Her Primary Dental Provider: His/Her Clinic:

8 About Clinica Page 8 Services, Patient Rights & Responsibilities About Clinica

9 Clinica has five locations. We try to assign you to the clinic that is closest to where you live. Once you choose your health care provider, we want you to see that provider whenever possible. Your provider is part of a team of health care professionals, all working together to provide you the best care possible. We believe that you receive better health care if you see the same person or same team of people at each visit. When you schedule an appointment, we will try to make sure that you see your provider or a member of your provider s team. Services We Offer Well visits Regular check-ups, sports or school physicals Acute care Care for an illness such as fever or sore throat Preventive care Screenings to help you stay well Obstetric and gynecological care Prenatal and women s care Minor surgical procedures Procedures not requiring anesthesia Cancer screenings Tests looking for cancer Health education Learning to take care of yourself Nutrition counseling Learning how to eat healthily Behavioral health care for individuals or families Help when you are depressed, anxious or have emotional problems Citizenship and Immigration Services (CIS) physicals Check-ups when applying for U.S. citizenship Immunizations Shots to keep children and adults healthy Dental care Care of your teeth Pharmacy services Filling prescriptions from your provider Outreach services Contacting you by phone or mail when you are due for an appointment. The medical and dental care that your provider gives you is based on the most current and proven practices currently used in medicine. Please ask us if you have any questions about your treatment plan. Services We Do Not Offer Medical X-rays or other imaging services (we do offer dental X-rays) Specialty care (please see page 17) Walk-in services Emergency care (please see page 19) Department of Transportation physicals About Clinica Page 9

10 Your Rights As Our Patient About Clinica Page 10 ACCESS. Appointments are provided within a reasonable period of time and charges will be affordable based on your family size and income. You will be treated without discrimination as to race, color, gender, national origin, political beliefs or handicaps. DIGNITY. Care is provided in a manner that respects your individuality and dignity. PRIVACY. All physical exams, interviews and discussions about your health will occur privately and your medical records will be handled confidentially. EMPLOYEE IDENTIFICATION. You have the right to know the names, professional status and experience of the staff who are providing your care. CONSENT. Consent for treatment will be requested by our medical staff before any procedure is performed. The procedure and its value, risks and other options for treatment will be explained. REFUSAL OF TREATMENT. You have the right to refuse any care recommended. ACCESS TO RECORDS. You may review or receive a copy of your medical record within 10 days of your written request for records. RESEARCH. You will be provided with information and an opportunity to consent before any experimental treatment and/or test. BILLS. You have a right to an explanation of all charges and slidingfee scale adjustments.

11 Your Responsibilities As Our Patient FOLLOW CLINIC RULES. Follow rules including the consideration of the rights of other patients and staff. Please assist with the control of noise and observe the no-smoking policy. INFORM. Please give full and honest information. This includes complete medical records or a complete medical history, information on any medications you take and any other providers that you see outside Clinica Family Health Services. REPORT CHANGES. Report any changes in your condition, symptoms and allergies. FOLLOW INSTRUCTIONS. Follow your health care provider s instructions. If you have any questions, please ask. About Clinica Page 11 BE ON TIME. Arrive for your appointment on time. If you need to miss an appointment, please call 24 hours in advance. REPORT EMERGENCIES. Call the emergency phone numbers provided to you if you suffer an emergency and notify your health care provider of any emergency within 24 hours. SHOW INSURANCE CARD. Show your insurance card (including your Medicaid ID card) at each visit. FINANCIAL SCREENING. Complete the financial screening process by bringing all insurance, income and other required information to the clinic within 30 days of your first visit. PAY BILLS. Your fees will be adjusted so that they are affordable for you. Please pay your co-payments and bills promptly.

12 Health Care Services Page 12 Pharmacy, Dental, Groups, Behavioral Health, Specialists, NextGen, Emergencies Other Health Services

13 Pharmacy Services Clinica has two full-service pharmacies with a pharmacist on staff to fill prescriptions while you wait. These are located at our People s and Pecos facilities. The Lafayette and Thornton clinics have pharmacy outlets. Outlets have a limited stock of medications and cannot usually refill prescriptions while you wait. While we stock many common medications, some prescriptions might need to be filled at a commercial pharmacy. For prescription refills, please call Please allow hours for your prescription to be filled if you call the refill line. This is especially true if you are picking up prescriptions at one of our pharmacy outlets. Pecos Pharmacy Monday Opens 8:30am Lunch 1-2pm Closes 5:30pm Tuesday 8:30am 1-2pm 7:30pm Wednesday 8:30am 1-2pm 7:30pm Thursday 8:30am 1-2pm 7:30pm Friday 8:30am 1-2pm 4:30pm Health Care Services Page 13 People s Pharmacy Monday - Friday Opens 8:30am Lunch 1-2pm Closes 4:30pm Lafayette Pharmacy Outlet Monday Opens 9:30am Lunch 1-2pm Closes 5:30pm Tuesday 9:30am 1-2pm 5:30pm Wednesday 9:30am 1-2pm 5:30pm Thursday 9:30am 1-2pm 5:30pm Friday 8:30am 1-2pm 4:30pm Thornton Pharmacy Outlet Monday - Friday Opens 8:30am Lunch 1-2pm Closes 4:30pm

14 Dental Services Health Care Services Page 14 We have two dental clinics. Patients who see medical providers at the Pecos, Federal Heights or People s clinics receive dental care at the Pecos Dental Clinic, located on the first floor of the Pecos Medical and Dental Clinic. Patients who see medical providers at either the Lafayette or Thornton clinics receive dental care at the Thornton Dental Clinic, located in the Thornton Medical Clinic. For dental appointments, call Dental Clinics Monday - Friday Opens 8am Lunch 1-2pm Closes 5pm WHO IS ELIGIBLE FOR CLINICA DENTAL CARE? Any patient with an established medical provider and a discount rating at Clinica is eligible for care in the Dental Clinics. New patient group visits do not count as having an established provider. New patients are welcome to our dental clinics! However, first priority for appointments is given to children under 18 years old, pregnant women and diabetic patients. We currently are accepting new pediatric patients at both dental clinics. Please call to make an appointment. For all others, appointments are given on a first-come, first-served basis, and there is often a waiting list to be seen. On most days, we have a few limited care appointments available for patients who have an urgent

15 problem (severe pain, infection or swelling), which are also available on a first-come, first-served basis. Please note that the goal of these appointments is to address one urgent issue only, not provide full treatment of the mouth. CLINICA DENTAL SERVICES We provide both general and specialty services for children and general dentistry for adults. For patients of all ages: exams, fillings, cleanings, some extractions and root canals. For children under 12 years old: crowns, nitrous sedation and hospital services. All other specialty services (crowns, bridges, implants, dentures or partials, cosmetic dentistry, complex extractions and complex root canals) are referred to dental providers outside of Clinica. You may meet one of our dental hygienists during a routine medical visit. Hygienists sometimes join group visits (see page 16) or meet with pregnant women, parents or children during one-on-one medical visits to provide important information on keeping smiles healthy, preventive dental treatments or assistance with obtaining dental services. Health Care Services Page 15 COST OF CLINICA DENTAL SERVICES Payment for dental treatment is due at or before the time of service, and the cost will vary depending on your insurance coverage or discount. The dental clinics accept Medicaid, CHP+ and the Clinica discount rating. Patients with other forms of dental insurance are encouraged to find dental care outside of Clinica. Patients with a Clinica discount will pay a portion of the total cost of their treatment, which will differ at each appointment, depending on the services they receive. You will be quoted prices on the services to be provided before each appointment. For more information, please contact one of our dental clinics.

16 Health Care Services Page 16 Group Visits In addition to traditional one-on-one appointments, Clinica offers patient care through group visits. A group visit is when 6-8 patients with the same health need are seen at the same time. Instead of meeting in an exam room, group visits are held in larger, more comfortable spaces. In addition to your clinician, members of your clinician s team join the groups. You receive all the care you would in an exam room, but you also get to hear from behavioral health professionals, nutritionists, dental hygienists or pharmacists. Groups are very interactive and last much longer than traditional appointments. You have time to ask questions, share past experiences and learn from other patients in the group. Participating in groups is voluntary, but many patients find group visits much more enjoyable than one-on-one care. Behavioral Health Services Your physical, mental and emotional health are linked. Keeping you healthy means that we want to help you take care of both your body and your mind. Every health care team has a behavioral health provider with specialized training to help you when you are depressed, anxious or experiencing other emotional problems. They can also help you quit smoking or work on family problems. These types of support from our staff are tailored to each patient s individual needs. These behavioral health provides works side-by-side with your primary care provider. They can provide short-term counseling and support in our clinics for behavior changes. Each of our healthcare teams also has a case manager who will work with you to set goals for improving your health and can link you with resources in the community that might help you.

17 Referrals to Specialty Care Occasionally you may need care or services that we do not provide at Clinica. In these situations we will refer you to an outside specialist for care. However, the availability of specialty care is very limited and, at times, may not be available to uninsured or underinsured patients. If you do see a specialist outside of Clinica, you are responsible for the bill. Please make time to work with the staff in the specialist s office on a payment plan. NextGen Patient Portal Patients can securely their clinica providers using a computer program called the NextGen Patient Portal. This is a free service that we provide to all of our patients. PATIENT PORTAL USES Routine medical questions and requests: send us an any time of the day. Request appointments on-line: enter the days and times you wish to come for a visit and we will you back with an appointment time. Medication refills: request medication refills for pick up at one of our pharmacies or an external pharmacy. Lab results: we will be able to send you certain lab results and other important personal health information. Search for patient health education information: the web site has options for accessing generic health information. Health Care Services Page 17 IMPORTANT POINTS ABOUT USING THE PATIENT PORTAL s should never be used for urgent or life-threatening medical problems. You can expect an response from us within 2-3 business days. Patient Portal communication will

18 Health Care Services Page 18 become a permanent part of your medical record. The reply to your may be from any member of your provider s team. If you sign up for the Patient Portal, please agree to check your several times a week since we will use this web site to communicate with you about your health care. You will need an enrollment token (it expires 30 days after you receive it) to complete enrollment at home. You can communicate on behalf of other family members via the Patient Portal. Inappropriate use of the Patient Portal may result in us terminating your access to the web portal. If you have any questions about using the NextGen Patient Portal, please call the Call Center or go to our web site at and look under the Patient Services tab for detailed instructions. Unfortunately we cannot help you with any internet connection issues or personal computer issues you may have. Although the web site is only available in English, we are happy to you in Spanish.

19 What is a Medical Emergency? An emergency condition is a medical or mental health problem that is severe and could cause permanent bodily damage or death. If you think you are experiencing an emergency, go to the nearest emergency room or call 911 immediately! If you are not sure what type of care you need, please see below for who to call. WHAT IS AN URGENT NEED? An urgent care need is one that requires prompt medical attention (usually within 24 to 48 hours) but is not an emergency condition. Examples of urgent care situations include: minor injuries, sore throats, upper respiratory symptoms, earaches, coughs, backaches, frequent urination or burning when urinating. If you have urgent symptoms, please call whether during normal business hours or after hours. FOLLOW-UP CARE You are responsible for calling the clinic for follow-up care after going to an urgent care facility, being seen in a hospital emergency department or being admitted to a hospital. Health Care Services Page 19 HOSPITALS WHERE WE SEE PATIENTS Clinica providers see hospitalized patients at Avista Adventist Hospital in Louisville. Clinica providers also work closely with staff at St. Anthony North Hospital in Westminster to care for Clinica patients. Hospital care is separate from what you receive at Clinica. If you are seen at a hospital, you are responsible for the bill. Please make time to work with the hospital on a payment plan. Avista Adventist Hospital 100 Health Park Drive Louisville, CO St. Anthony North Hospital 2551 W. 84th Avenue Westminster, CO

20 Patient Services Page 20 Appointments, Payments, Financial Screening, Feedback, Medical Records Patient Services

21 Making An Appointment Please call to make or cancel any appointment. We are not a walk-in or urgent care clinic. Please do not expect to see a provider unless you have an appointment. Our Call Center schedules visits for all of our clinics. In order to see all of our patients and stay on time, we must limit appointment times. We may not be able to meet all your needs in one visit, so you may have to come back for a follow-up appointment. Come to your visit on time. If you are more than 15 minutes late for your appointment, you may need to reschedule your visit. Please call the Call Center if you need to cancel an appointment. If the Call Center is closed, please leave a message on the cancellation message line. Excessively or repeatedly missing appointments without canceling may lead to us terminating your care at all Clinica locations. We offer sameday appointments in many cases and will try to find you an appointment time within 48 hours of when you call us. Family members are allowed to make, confirm, reschedule and cancel appointments for other family members. Please let us know if you wowuld like to place limitations on your account. Patient Services Page 21

22 When To Call Us Clinica has a Call Center with staff who are specially trained to answer your questions, make or cancel appointments for each site or put you in touch with a nurse if necessary. The Call Center is open: Call Center Patient Services Page 22 Monday Opens 8am Lunch 1-2:20pm Closes 5pm Tuesday 8am 1-2:20pm 5pm Wednesday 8am 1-2:20pm 5pm Thursday 8am 1-2:20pm 5pm Friday 8am 1-2:20pm 4pm PLEASE CALL US FOR: Scheduling or cancelling an appointment Medication refills (might take up to 72 hours) Questions about medications Concerns, complaints or compliments Leaving a message for someone on your provider s team Lab results Cancelling appointments even when the clinic is closed WHO TO CALL WHEN WE ARE CLOSED If you have an urgent problem that requires immediate attention during non-business hours, please call for directions on how to speak with the person on call

23 Payment Programs at Clinica Clinica is a Federally Qualified Health Center (FQHC). We receive funding from federal, state, county and city agencies that helps us serve patients who are uninsured, underinsured or have Medicare, Medicaid or CHP+. All Clinica patients must complete an annual financial screening process to determine which of our payment programs is best for you and your family. MEDICAID AND CHP+ Family Medicaid and CHP+ are public health insurance programs for families, children and pregnant women that are provided by the State of Colorado. When you apply, you are applying for both Family Medicaid and CHP+. The program you qualify for depends upon your family s size, income and the age of the applicant. Clinica can assist you in completing these applications at our sites and send the applications to the appropriate agencies for processing. CICP The Colorado Indigent Care Program (CICP) provides funding to clinics and hospitals so that medical services can be offered at a discount to Colorado residents. Patients must meet the eligibility requirements established by the State of Colorado. All applicants must go through an application process yearly and must meet the following requirements to participate in CICP: Patient Services Page 23 Must be a Colorado resident or migrant farm worker and a U.S. citizen or legal immigrant. Must have combined income and resources at or below 250% of the federal poverty level. Cannot be eligible for Medicaid or Child Health Plan Plus (CHP+). CICP is NOT a health insurance program and is limited in where it can be used and what it covers. CLINICA SLIDING-FEE SCALE Clinica s sliding-fee scale is based on your family size and income. It is used for patients who do not qualify for CICP and have incomes at or below 200% of the federal poverty level. You do not have to prove that you are a Colorado resident to qualify for our sliding-fee scale.

24 PRIVATE INSURANCE If you get insurance after you become a Clinica patient, through an employer or through a health exchange, you will most likely be able to continue your care at Clinica. We accept most types of private insurance. We will bill your private insurance for all charges. If you have a high deductible or co-payment, you may use your sliding scale to cover part or all of your co-payment amount. Patient Services Page 24 SELF-PAY If your income is above 250% of the federal poverty level and do not qualify for any of the above plans, you would be considered a self-pay patient. You would be responsible for payment of all medical and lab services at the full fee. IMPORTANT NOTE Your Clinica discount is not health insurance. The discount you have for health care at Clinica might not be accepted at health care facilities outside of Clinica. Always check on costs and payment policies when receiving health care services outside of Clinica. If you receive care at an area hospital or specialist s office, Clinica is not responsible for paying those expenses. Billing Department To reach the Billing Department, please call Billing Department Monday - Friday Opens 7:30am Lunch 1-2pm Closes 4:30pm BILLING STATEMENTS Patients with an outstanding balance receive a statement every 28 days. Statements only go to patients with a balance of $10 or more. MAKING PAYMENTS Patients can make payments with a credit or debit card on-line at www. clinica.org or by calling PAYMENT PLANS We offer payment plans without any penalty. If you would like to set up a payment plan, please call us at

25 Financial Screening Financial screening is a process of determining which payment program you and your family qualify for or how much you should pay on Clinica s sliding-fee scale. Because your financial situation can change, we require patients to update their financial screening every year. Please make financial screening appointments by calling the Call Center. Following is a list of documents that you might need to bring to your financial screening appointment. Picture ID for all adult applicants Car registration Social Security numbers for entire family Legal Permanent Resident Card if resident of US Proof of address under patient s name: utility bill, water bill for either the previous or current month Insurance, Medicaid and/or Medicare cards Proof of unearned income: child support, SSI, DSSI, unemployment If self-employed, bring last month s business ledger If pregnant, bring proof of pregnancy, Social Security card and picture ID or birth certificate Passports, birth certificates, Colorado IDs or school IDs for all children under 18 All check stubs from previous month or signed and dated letter from employer stating hours worked per week, pay per hour, if you are paid weekly or bi-weekly and gross income from the last month If living with someone else, bring signed and dated letter from that person. Letter should include address, phone number and when you moved in. Also bring a utility bill for previous or current month from that person. Patient Services Page 25 Bring all necessary documents to your appointment. You will not be financially screened if you arrive without the necessary documents. If you cannot bring one or more of the documents, please cancel your appointment and reschedule once you have all thee documentation. My type of discount: Date when my discount expires:

26 Financial Screening Hours At Administration Monday Opens 8am Lunch 12:40-2pm Closes 5pm Tuesday 8am 1-2pm 5pm Wednesday 8am 1-2pm 5pm Thursday 8am 1-2pm 5pm Friday 8am 1-2pm 4:30pm Patient Services Page 26 At Pecos Monday Opens 8am Lunch 1-2:20pm Closes 5pm Tuesday 8am 1-2pm 7:30pm Wednesday 8am 1-2:20pm 7:30pm Thursday 8am 1-2pm 7:30pm Friday 8am 1-2pm 4:30pm At People s* Monday Opens 8am Lunch 1-2pm Closes 5pm Tuesday 8am 1-2pm 5pm Wednesday 8am 1-2pm 5pm Thursday 8am 12:45-2pm 5pm Friday 8am 1-2pm 4:30pm * Hours vary. Please check with the Call Center when making an appointment.

27 Your Comments Count Clinica is very interested in your feedback on how we can improve your experience as a patient. If something went well or did not go well, we want to know so we can improve our customer service. We have cards at each Clinica site to collect your impressions. These are called Your Comments Count cards. If you ever want to share suggestions or comments (good or bad), ask any Clinica employee for a Your Comments Count card. Fill out the information and drop it off at the clinic or mail it in, whichever is more convenient for you. You can also contact the Call Center and an attendant or a manager can take your information. Your Comments Count cards are available at all of our medical and dental clinics and at the administration office. All Your Comments Count cards are reviewed by a manager. You will receive a call from a clinic manger regarding your comment or suggestion so that you know we received your feedback. Remember, you are the best person to tell us how we can better serve you. Patient Services Page 27 Medical Records You have the right to request a copy of all or a portion of your medical records at any time. We are only allowed to release your Clinica records to you. If you are interested in obtaining a copy of your medical records, you will need to complete an Authorization For Release Of Medical Information form. You may obtain one of these forms at your clinic. Please know that processing these requests may take 3-5 business days, and there may be a charge associated with obtaining your records.

28 Health Information Page 28 Health Information, BMI Scale, Blood Pressure Table, Health Goals Your Health Records

29 My Health Information Date Weight Blood Pressure Pulse Total Cholesterol HDL (good cholesterol) LDL (bad cholesterol) Blood Sugar Health Information Page 29 MY NEXT DENTAL APPOINTMENT IS: Date: Time:

30 Health Information Page 30 Body Mass Index (BMI) BMI Height Top number (systolic) Bottom number (diastolic) Your category Below 120 and Below 80 Normal blood pressure Weight in pounds Healthy weight Overweight Obese Blood Pressure What to do Maintain or adopt a healthy lifestyle or Prehypertension Maintain or adopt a healthy lifestyle or Stage 1 hypertension Maintain or adopt a healthy lifestyle. If blood pressure goal isn t reached in about six months, talk to your doctor about taking one or more medications. 160 or more or 100 or more Stage 2 hypertension Maintain or adopt a healthy lifestyle. Talk to your doctor about taking more than one medication. * Ranges may be lower for children and teenagers. Talk to your child s doctor if you re concerned your child has high blood pressure.

31 My Health Goals My nutrition goal: My fitness goal: My behavioral health goal: Health Information Page 31

32 OP /13-PR Clinica is recognized by the National Committee for Quality Assurance as a Level III Patient Centered Medical Home.