I understand that as part of my medical care, Bee Busy Wellness Center (BBWC) creates and maintains paper and/or electronic records that describe my medical history, symptoms, examination 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 diagnostic and surgical information to my bill,
• A means by which a third party payer can verify that the 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 the uses and disclosures of the information. I understand that I have the following rights and privileges:

• The right to review 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 that the organization has already taken action in this regard. I also understand that by refusing to sign this consent or by revoking this consent, this organization may refuse to treat me as permitted by Code of Federal Regulations Section 164.506.

I further 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 OCHIN participants. An updated list of OCHIN Participants is available at www.ochin.org as a business partner of other OCHIN Participants. ochin it also engages in quality assessment and improvement activities on behalf of its participants. For example, OCHIN coordinates clinical review activities on behalf of participating organizations to establish standards of best practices and evaluate the clinical benefits that can be derived from the use of electronic medical record systems. ochin it also helps participants to 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 Sharing of health information only when necessary for medical treatment or for purposes of operations of health care from the organized health care arrangement. The health care operation may include, among other things, geocode your location of residence to enhance 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 that it is 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 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 this organization's treatment, payment or health care operations, it may be necessary to disclose protected health information to another entity and I consent to such disclosure for these permitted uses, including disclosures by fax. 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 planned 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 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 submitted to Medicaid/Medicare for reimbursement to the health care facility and assignment must be accepted. I will carry my current Medicaid/Medicare certification letter with me each time I visit the health care 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 proper 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.