I, understand that as part of my health care, Bee Busy Wellness Center (BBWC) creates and maintains paper and/or electronic records that describe my medical history, symptoms, examinations and test results, diagnoses, treatments and any plans for care. or future treatment, I understand that this information serves as:

• A basis for planning my care and treatment,
• A means of communication between the many health professionals who contribute to my care,
• A source of information to apply my diagnosis and surgical information to my bill,
• A means by which a third-party payer can verify that billed services were actually provided,
• A tool for routine healthcare operations such as quality assessment and competency review of healthcare professionals.

I understand and have received BBWC's Notice of Privacy Practices which provides a more complete description of uses and disclosures of information. I understand that I have the following rights and privileges:

• The right to review the notices before signing this content,
• The right to object to the use of my health information for directory purposes, and
• The right to request restrictions on how my health information may be used or disclosed to carry out treatment, payment or health care operations.

I understand that BBWC is not required to agree to the requested restrictions. I understand that I may revoke this consent in writing, except to the extent the organization has already taken action. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the code of Federal Regulations.

Additionally, I understand that the agency reserves the right to change its notice and practices prior to implementation in accordance with section 164.520 of the Code of Federal Regulations. If the agency changes its notice, it will send a copy of any revised notice to the address I have provided (either by fax, US mail, or if I agree, by email).

Bee Busy is part of an organized health care arrangement that includes participants in OCHIN. An updated list of OCHIN Participants is available at www.ochin.org as a business partner of other OCHIN Participants. OCHIN It also participates in quality assessment and improvement activities on behalf of its participants. For example, OCHIN coordinates clinical review activities on behalf of participating organizations to establish standards of best practices and evaluate the clinical benefits that may arise from the use of electronic medical record systems. OCHIN It also helps participants work collaboratively to improve the management of internal and external referral of patients. Bee Busy Wellness Center Center may share your personal information with other OCHIN participants or a exchange of health information only when necessary for medical treatment or for the purposes of business operations. organized health care arrangement. The healthcare operation may include, among other things, geocode your residential location to improve the clinical benefits you receive. Personal health information may include past, present and future medical information, as well as information described in the Privacy Rules. Information, to the extent disclosed, it will be disclosed from time to time. You have the right to change your mind and withdraw this consent, however, the information may have already been provided as permitted by you. This This consent will remain in effect until you revoke it in writing. Upon request, you will be provided with a list of Entities to whom your information has been disclosed

I want to allow BBWC to share my health information with the following people:

I understand that as part of the treatment, payment or health care operations of this organization, it may be necessary to disclose protected health information to another entity and I consent to such disclosure for these permitted uses, including facsimile disclosures. I fully understand and accept the terms of consent.

(one year from the date of my signature, unless otherwise specified or revoked by me in writing)

Bee Busy Wellness Center (BBWC) is a private, non-profit health center. Standard rates have been established for all provided services. BBWC is not a city or county clinic. Any additional costs, including labs and x-rays, will be at an additional cost to the patient.

If I apply for the discount program (Sliding Scale) I will be charged based on my total family income and the number of people in my household.

If I have Medicaid or Medicare, charges for my visit and services received will be sent to Medicaid/Medicare for reimbursement to the healthcare facility and assignment must be accepted. I will carry my current Medicaid/Medicare certification letter with me each time I visit the healthcare facility.

I authorize my health insurance benefits to be paid directly to the health center. I further understand that I am financially responsible for any balance due. My signature below authorizes BBWC and/or my health insurance company to release any information required to process my claims.

I understand that BBWC offers a Sliding Fee Scale program for individuals and families experiencing financial hardship. It is my responsibility to provide BBWC with the appropriate financial documentation requested to determine my eligibility for this discount. Additionally, I understand that I must update my financial information if a change occurs between visits.

I have read and understand the BBWC payment policy.