Welcome! A few things you need to know about being our patient.

Welcome! A few things you need to know about being our patient.

Our Programs and Locations Our Medical and Behavioral Health Programs: In Jefferson County: We see children in our pediatric office, school-aged students in our school-based health centers, and adults in our Adult Medical office. Adult Medical: (315) 782-9903 Pediatric: (315) 782-6400 School-Based Health Centers (see page 16) In Lewis County: We see children and adults in our Family Health Center in the rear wing of Lewis County General Hospital. Family Health Center: (315) 376-4500 In our Dental Program We see adults as well as children. Watertown: (315) 788-9834 Our school-based health program provides dental care to students in the Watertown and South Jefferson Schools (see page 16) In our WIC Program We see pregnant women and breastfeeding mothers, as well as infants and children. Jefferson County: (315) 782-9222 Lewis County: (315) 376-6427 St. Lawrence County: (315) 386-8128 Franklin County: (518) 483-4262

Welcome! North Country Family Health Center provides healthcare to adult and pediatric patients at our offices at 238 Arsenal Street in Watertown, NY and at 7785 N. State Street in Lowville. We see patients who choose us as their primary care provider and provide medical care that is comprehensive, coordinated, and accessible. Everyone is welcome at the Health Center. We accept patients with private insurance, military insurances, Medicaid, and Medicaid Managed Care plans and offer a sliding fee to individuals without insurance, or those who are unable to pay their high deductible or co-pay. For more about our Sliding Fee Scale see page 10. We welcome patients with disabilities, have translation and interpretation services available for patients who do not speak English and are always happy to help patients who have trouble reading, writing, or understanding medical information or forms. 1

Great Customer Service is Important to Us! We will respond to any reasonable request courteously and promptly. We will respect your privacy. We will make every effort to communicate with you in a way you can understand. We offer over the phone translation and interpretation services. We will provide care that takes into consideration your personal, spiritual, and cultural values. We will take your comments and complaints seriously. If you are pregnant, breastfeeding, or have a child under age 5 See if you qualify for WIC. WIC is co-located with our Health Centers in Watertown and Lowville 2

Contents Office Policies...................... 4 Choosing a provider................. 4 What to bring to your appointment...... 4 Electronic Health Records & prescriptions. 5 Patient Portal....................... 5 Phone calls........................ 5 Missing your appointment............. 5 When our office is closed............. 6 Paying for your Healthcare............ 7 Patients with insurance............... 7 Self-pay patients.................... 8 Finance policies..................... 9 Extra Charges...................... 9 Sliding Fee Scale................... 10 Consent Forms.................... 12 Other Forms....................... 13 Patients Rights.................... 14 Patients Responsibilities............ 15 Other Services We Offer............. 16 3

Our Office Policies Choosing a Provider: Many of our programs has more than one provider (doctor, dentist, nurse practitioner, physician assistant and psychologist). You have the right to see the provider of your choice. We will make every effort to schedule you with the provider you prefer, but in some cases, that may not be possible and you may need to see another provider in our office. What to Bring to EACH Appointment: A driver s license or other state issued photo ID Utility bill or other correspondence showing current residence if photo ID does not show your current address Your social security number A valid insurance card - if you have insurance Your co-pay- if your insurance has co-pays Pill bottles or names of all medications you take If you have no insurance: We have a Sliding Fee Scale that will make your care affordable. For more information about our Sliding Fee Scale see page 10. If you have new insurance and have not yet received your insurance card: You will need the following information: insurance company name, claim address, co-payment amount, policy holder name, policy number, and group number. 4

Our Office Policies No Shows and Late Shows If you will not be able to keep an appointment, please call our office to cancel as far in advance as possible so that we can see another patient in that time slot. If you are more than 15 minutes late for an appointment, we may have to reschedule you on a future date or you may need to wait to be seen that day. Telephone Feel free to call us during office hours. Many problems can be solved with advice over the phone, saving you the time and cost of a visit. Sometimes, to give you the best possible advice, we may need to call you back so we have time to review your chart and speak with a provider. We are happy to provide this service, but it is against the policy of this office to treat a serious illness over the phone or to treat a patient who has never been seen in our office. Medical Records and Secure Patient Portal Our office uses Electronic Health Records (EHR) because they are safer, more accurate, and easier to use than paper files. You have 24-hour access to your EHR through a secure Patient Portal. Each patient is given instructions about using our secure patient portal. Once you have registered, you can easily view your medical record, check lab results, send a secure message to your provider, and check your appointment schedule. Physical Forms Please allow up to 3 business days for these forms to be filled out unless you bring them with you at the time of your appointment. Prescriptions Our offices uses e-prescribing. Instead of writing out your prescription on paper, your prescription travels from our computers to the pharmacy of your choice. E-prescriptions are sent electronically through a private secure and closed network. Prescription Refills Please allow up to 3 business days to process a prescription refill. 5

When our Office is Closed Emergencies: DIAL 911 or go to the Emergency Room when you or a family member could die or risk their health without immediate medical attention. Examples: When bleeding won t stop; when breathing is very hard; after a serious accident; after a convulsion that lasts more than 3 minutes. After Hours: When our office is closed, we are still available to our patients. One of our providers can be reached, even when our office is closed, by calling our office number. We ask that this service be used only for urgent problems. Please leave routine calls for regular office hours. Adult Medical Office: (315) 782-9903 School-Based Health Centers and Pediatric Office: (315) 782-6400 Dental Office in Watertown: (315) 788-9834 Lowville Family Health Center: (315) 376-4500 When you call us after-hours, your call will be answered by our answering service or a registered nurse. They are trained to help you with questions and will have a provider call you if necessary. 6

Paying for your Healthcare Methods of Payment We accept cash, checks, debit cards, Visa, MasterCard, and Discover. We do not accept post-dated checks, nor are we able to hold checks for any length of time. Billing and Payment Policies If you have a charge or a co-pay, we expect you to pay them on the day of your visit. If you are having trouble keeping up with your bill payments, we can work out a payment schedule that you can afford. We also offer a Sliding Fee Scale (see page 10). Your Insurance We will bill your insurance company for services. To do that we need insurance information that is up-to-date and correct. You can help us by: 1. Bringing your insurance card with you to each appointment. 2. Paying your co-pay and other payments due on the day of your appointment. 3. Calling our billing office at 1-877-476-8370 if you have any questions about your account. 4. Making sure you have named one of our doctors as your Primary Care Provider (PCP). We expect you to talk with your insurance carrier, if you have any open claims. You should normally get a response from your insurance company within 30 days. This is in the form of an Explanation of Benefits (or EOB). Please remember, you are responsible for payment of any balance that is not paid by your insurance company. Sometimes an insurance company will pay you directly for the services provided by NCFHC. Please be aware that if this happens, it is your responsibility to endorse the check, attach the explanation of benefits that came with it, and pass that payment along to NCFHC. Please note: We are not a Workman s Compensation Claim provider. 7

Paying for your Healthcare If You Become Uninsured If your insurance coverage is cancelled or discontinued, please call one of our patient financial representatives immediately: (315) 782-9450 (then press # 6). We will work with you to create a payment plan that you can afford, so that you can continue coming for regular visits and needed care. We can help you find out if you qualify for Medicaid or Child Health Plus, or for affordable health insurance through the New York State of Health Marketplace. If one of these programs is right for you, we have someone on staff who can help you apply. Self-Pay Patients Self-pay patients are those not covered by any insurance policy or third party payer. If you can t pay your bill, we will work with you to set up a payment plan you can afford. Please call one of our patient financial representatives at 1-877-476-8370 to talk about payment options, before your account becomes past due. Payments may be made by cash, money order, check, or credit/debit card. Note to divorced parents of dependents: Unless you provide us with a court order, we must assume that both parents are responsible for the child s bills. We will send our statement to the address where the child lives. It is up to the parents to determine who pays. How to Contact Us If you need help or have any questions about your bill, our Billing Department can be reached at 1-877-476-8370. Please keep us informed of your insurance status and any changes in your address or telephone number(s). 8

Returned Checks Paying for your Healthcare Billing Statements Statements are sent every month. If you notice any errors on your statement or if you are not able to pay the balance in full, please contact our Billing Department at 1-877-476-8370. If for any reason your statement is returned to our office because of a problem with an address you provided, your account will be referred to our collection agency. To keep this from happening, please keep your information up-to-date. Personal balances over 90 days past due will be forwarded to our collections agency. If a check is returned unpaid to the Health Center, a $30.00 fee will be added to your account balance in addition to the amount of the check written. A letter will be sent to you requesting the check amount and the fee be paid in cash within 14 days. Extra Charges: For Self-Pay Patients Some diagnostic tests that are done outside of our health center (like blood work, lab cultures, and x-rays). Consults with specialists and other specialty care. * IMPORTANT: The labs and other care providers we work with have sliding fee scales and you may be eligible for reduced fees based on your income. For Insured Patients Sometimes, if the insurance information we send along with your lab work is not correct, outside labs can t process the charges and they will send you a bill. Please make sure we have your correct insurance information on file (including your insurance ID number and expiration date) so that this doesn t happen. 9

Sliding Fee Scale Our sliding fee discount is for anyone whose household income is at or below 200% of the Federal Poverty Guidelines. Household includes all people living in the same house or apartment even if they are not related to you. After you fill out the Sliding Fee Scale Application we can tell you how much we can discount your fee. We can use this discount for any amount due and for any services we offer. We will give you the care you need no matter what you can pay. 2015 Sliding Fee Schedule 10

Sliding Fee Scale How to apply for our sliding fee discount: Our front desk staff can help you apply. Step one, asking about your household size and income, is always done as part of check-in. To apply for a discount, we ask you to fill out a short form and show us proof of income. If you don t have proof of income on your first visit, we can give you 30 days to show us the paperwork we need. What you need to bring for proof of income : If you are EMPLOYED: a copy of last year s income tax return. OR If you did not file a return: a W-2 OR pay stubs from last 30 days OR written statement from your employer If you are NOT EMPLOYED: Proof of Social Security income Proof of Unemployment income Proof of Disability income. Proof of other income (if you have it) like child support, alimony, or retirement pension We will ask you to update your Sliding Fee Application every year. 11

Our Consent Forms All medical offices ask new patients to sign many forms and releases. When you become our patient, you will sign four consent forms. You may ask for a copy of any of these forms: Consent for Treatment Allows us to treat you, do HIV testing if necessary, and share prescription history and patient information according to state and federal laws. It also says you are responsible for your bill and give us permission to bill your insurance company. HIPAA Release Explains how your personal health information is protected and under what conditions we will release it to someone else. This form needs to be signed every year. Our Finance Policy Explains that you have a right to be treated whether you are covered by insurance or not. It further explains that if you have no insurance, or have a plan with a high deductible, you may be eligible for our sliding fee scale and if you do have insurance, we will bill your insurance company for services we provide. You are responsible for uncovered costs. Health Connections - the Regional Health Information Organization (RHIO) This is the consent form that gives us the right to review your medical information from other healthcare agencies so we have all the information we need to make the best medical decisions. This consent also allows all of your providers to share your health information so that everyone knows what the others are doing. 12

Other Forms you May Need We can provide you with a copy of these forms. Please see the front desk staff, or ask your provider for more information. Release of Patient Information To provide medical information to you or to another medical provider that you request, we need a signed Release of Information form. Advance Directive Advance directives are legal documents that allow you to convey your decisions about end-of-life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on. Advance Directives include: Healthcare Proxy This form names someone to make medical decisions for you if you become too sick to make them yourself. Healthcare Proxy forms are available at our front desk, and on our website. Medical Orders for Life-Sustaining Treatment (MOLST) MOLST is intended for patients with serious health conditions who: want to avoid or receive any or all life-sustaining treatment. Authorization for Treatment Authorization for Care of an Unaccompanied Adolescent: Allows a teen to be treated without a parent/guardian present. Authorization to Sign for Medical Care: Allows a relative or friend to sign for your child s medical care. 13

Our Patients Rights To receive considerate and respectful care regardless of sex, age, race, religion, disability, color, national origin, gender, sexual orientation, or other personal characteristics including source of payment of your/or your child s care. To receive the information you need about your/or your child s health and medical conditions in a way you can understand, including interpreter services if you need them. To be involved in plans & decisions about your/or your child s treatment, so that you can give your informed permission before any diagnostic or therapeutic procedure is performed. To refuse treatment and be informed of consequences. To seek a second medical opinion. To expect reasonable continuity of care and have a provider of your choice who is responsible for coordinating your care. To know the names and positions of people involved in your/ or your child s care by name tag or personal introduction. To ask for special arrangements if you have a disability. To know about the cost of your/or your child s care; your eligibility for insurance help; and our Sliding Fee Scale and payment plan options. To receive information on after-hours coverage. To expect that your/or your child s medical record will be kept confidential and released only with your written consent EXCEPT in cases of medical emergency, in response to court orders, suspected abuse, or if you threaten to harm yourself, others, or property. The members of your health care team will share among themselves the information that is necessary to guide their care of you. (For more information about your right to privacy please read carefully your HIPAA statement and Notice of Privacy and consent to treat forms.) 14

Our Patients Responsibilities To provide honest and complete information about your past health and medical history so that we can provide the right care. To bring all the documents we need for each appointment, including a photo ID. To ask questions if you do not understand the explanation of your illness or any instructions we give you. To speak and behave respectfully to North Country Family Health Center staff and other patients. To respect the privacy of other North Country Family Health Center patients. To pay your North Country Family Health Center bills or, if you are having difficulty, call us to arrange a payment plan. To arrive on time for scheduled appointments. To call at least 24 hours in advance of your appointment to cancel and/or reschedule so that another person can have that time slot. To use medications only as prescribed. To follow the treatment plan recommended by your healthcare team and to be responsible for your actions if you refuse treatment or do not follow your health team s instructions. To recognize the effect of your life style on your personal health and try to make healthier lifestyle choices. 15

Other Services We Offer To our medical patients (pediatric and adult) Behavioral Health Counseling Ask your provider for a referral to this service. To pregnant or parenting moms needing extra support Healthy Outcomes - 836-7817 To anyone who is homeless or has insecure housing Healthcare for ALL - 782-9450 ext. 8086 To students who attend Watertown Schools School-Based Health Centers: North Elementary School - 786-1767 Wiley Intermediate - 785-3783 Case Middle - 785-3809 Watertown High School - 785-3703 our School-Based Program includes dental care Wiley Intermediate - 779-5611 Ohio Dental - 785-3755 North Elementary Dental - 779-5415 To students who attend South Jefferson Schools School-Based Health Centers: Mannsville Elementary - 465-3373 Wilson - 583-5200 our School-Based programs include dental care Mannsville - 465-3378 Wilson - 583-5349 Clark - 232-9968 To students who attend Lowville Schools Lowville Academy - 376-9000 To individuals and families without insurance Assistance with Enrolling in Affordable Insurance - 782-9450 press # 5 16

North Country Family Health Center is a Federally Qualified Health Center (FQHC) A FQHC is a Community Health Center, selected by the federal government to receive special funding because they provide comprehensive, quality care to anyone who needs it, regardless of ability to pay. Community Health Centers provide high-quality healthcare that is affordable and accessible. As an FQHC we offer one-stop shopping -- primary and preventive health care visits, lab services, dental, and behavioral health services and case management -- all conveniently located, coordinated, and tailored to meet your needs. North Country Family Health Center is a Patient Centered Medical Home (PCMH) Being patient-centered means that our health care team works with you as a partner in your care and coordinates your care both inside and outside of our office. We provide you with better, more personalized care, because our team knows you and your health history. We guide you through the complex healthcare system to help you get the care you need from us or others. We provide a safe place to talk about your concerns, and offer responses to all your questions and concerns at each visit.

We are committed to communication: We will make every effort to communicate with you in a way you can understand, including providing interpretation and translation services. If you have had a problem with your care, we want to know! Comments, suggestions, and complaints can be made to: Our Clinical Operations Officer Kim Thibert 238 Arsenal Street Watertown, NY 13601 (315) 782-9450 or kthibert@nocofamilyhealth.org Our website: www.nocofamilyhealth.org Our Executive Director - Joey Marie Horton 238 Arsenal Street Watertown, NY 13601 (315) 782-9450 or jhorton@nocofamilyhealth.org Our Corporate Compliance Hotline (315) 955-6480, ext. 8066 The New York State Department of Health 1(800) 628-5972