SAN· JUAN· BASIN

I-EALtl-lDEPARTMENT

HCP Specialty Clinic Information Sheet

Health Care Program for Children with Special Needs (HCP): Connecting Kids to Care

What is the purpose of the HCP Specialty Clinics?To bring pediatric specialty doctors for children birth to 21 years of age to rural areas of Colorado.The Clinics help families so that they do not have to travel to Denver or other distant metro areas fortheir child/youth to see a pediatric specialist.

What are the types of Specialty Clinics?The Clinics include doctors who specialize in neurology (brain and nerves). orthopedic (bones),rehabilitation (muscle), and otolaryngology (ears and throat), pulmonology (lung).

Who can refer a child to an HCP Specialty Clinic?If you think your child needs to be seen at an HCP Specialty Clinic, you can call your local HCP officeto make arrangements for a visit. It's important for your child's primary care provider to know thatyour child may be seen in the Clinic. HCP will work with you to help your child's provider make thereferral to the Specialty Clinic. If your child does not have a primary care provider, the HCP officecan help you find one. Many insurance companies require that the primary care provider make areferral to the clinic or they will not pay for the visit. Asking your child's primary care provider forthe referral also supports HCP's goal that your child has coordinated health care or a "Medical Home."

Who are the HCP Specialty Providers?The HCP specialty providers are pediatric board certified doctors who have agreed to work with HCP.They agree to take their time to travel from Denver and other cities to your local community.

Who are the HCP Team Members in the HCP Specialty Clinics?HCP Team members you will see include: a nurse, Judi Williams RN; dietitian, Jennifer Harrison RD LD;physical therapist, Cindy Kraushaar RPT; social worker, Liza Tregillus MSW; parent consultant, JillBrooks; Audiologist, Chandace Jeep; Speech pathologist, Marilyn Monger SLP. This Team is availableduring the clinic to provide you with information and help you with any follow up your child may need.

What is the HCP Clinic Fee?The Clinic Fee helps to cover the local health department costs for providing the clinic staff, clinicspace, clinic supplies, and clinic equipment.

How are the HCP Specialty Doctors Paid?HCP provides some payment for the HCP specialty doctors to see patients in the HCP Specialty Clinics.Also, the HCP specialty doctors do bill your child's insurance for the visits including Medicaid, CHP+,and private insurance. If your child has private insurance but has not yet met the deductible, you mayreceive a clinic visit bill from the physician's office. If the clinic doctor works at Children's Hospital,you may receive a bill from their billing company, UPI (University Physicians, Incorporated).

What if I get a call or letter from an insurance companyor billing company?We make every attempt to obtain available insurance for families before clinic and we willwork toassist those who do not currently have insurance. If you receive a letter or call from an insurancecompanyor a doctor's billingcompany,you should call them back right away. Sometimes they just needmore information or clarification. If you have questions contact your HCPClinicCoordinator right awayfor help.

Where can I get more information about the HCPSpecialty Clinics?For more information about the HCPSpecialty Clinicsyou can call: 1-970-247-5702 ext. 2023 or go tothe HCPWeb Site at www.hcpcolorado.orgor San Juan Basin Health Department Website atwww.sjbhd.org

Name of Your Ha> Clinic Coordinator: Judi Williams RNContact Infonnation: 1-970-247-5702 ext. 2019, judi@sjbhd.org

SAN· JUAN· BASIN

I€I1Lt1-1DEPARTMENT

HCP Family Information QuestionnaireSan Juan Basin Health Department

Address: PO Box 140, Durango, CO 81302Phone: 1-970-247-5702 ext. 2023, Fax: 1-970-247-9126

DATE""Child's Name"~'.. ' ,-.'. ."'.

M F Birth date Age

R,ac.iiJ~th1JicitY. ~. .. .'.' " " 'Ethnicity... '

o Alaska Native o African American o American Indian o Hispanic o Non-Hispanico Asian .0 CaucasianlWhite o Othero Pacific IslanderPa1flrlt7,Gliiitd;iiiJ'Ctr··"~ivrit.:'{iJfoiinatiolfc' . y> '. ' . ."

••••':••':'< •.. ,,'.,','; ,•••'s:····0'··'.··."..·.·.• ',<l:!!!1.............. ..'. "; ... ' .' . ..' . :.' -: "':.'"Number of Adults in the home: Number of Children in the home:

Parents Birth date Age Place of Employment: Phone Number

Mother's name:

Father's name:

Mailing address: Zip: Parent's e-mail:

Home address (if different) Zip: Home phone: Cell phone(s):

Family Emergency Contact with phone number: Language spokenlRead: Non English Speaking Only: _

Guardian Provider name: Guardian Phone Number:

Guardian Mailing Address

Childs Social Security #:

Household I Family Members (not including M F Age Relationship to Child Contact Phoneparenl{s) listed above): Numbers

School District I Contact name: Number:

Insurance' information: (Please check aU that apply)_ Private Insurance (Company name) Number:_Medicaid; __ CHP+; __ SSUSSDI ; __ No Insurance; ___ Number:

FOil H.CPSPECi~LTYCLINICSDr IF INTERSTEDINOTHER POSSIBLE ELIGIBLE COMMUNITY SERVICES

To qualify for the HCP sliding scale clinic fee or if interested in other eligible services please estimate your family'shousehold income: Annual Income: OR Monthly Income

All HCP families will qualify for an adjusted Specialty Clinic fee scale.

Family Member Providing Information: Relationship: _HCP Coordinator or Family Care Coordinator: Date : _

5-1-10 Family Information Questionnaire Revised

SAN • JUAN • BASINl-EdL[I-IDEPARTMENT

C Patient Name0 Last First..•.. .-

C.•... Birth Date Pbone#

~ ~.- S..•.• Addresseo: ~Il.t c£ Street City

C Parent/Guardian Completing Form~

--'.'.".-------------'--~-~---------------------.

MI

State Zip Code

III<1#..•.. c.J

C .-<1# CIIIC <1#0 r.FlU ~c8

c.-. C00 .-

<1#.•...~III Seo:

<1# ~- c8<1#~ C-

I hereby consent to the provision of services induding examination, routine diagnosticprocedures and non-surgical medical treatment, induding therapy, by the physicians and/ortechnicians or health professionals designated by the Southwest Region Health Care Programfor Children with Special Needs (HCP). I am aware that the practice of medicine is not an exactscience and I acknowledge that no guarantees have been made to me as to the result oftreatments, examination or therapies.

J authorize the Southwest Region Health Care Program for Children with Special Needs, torelease and exchange information with the following agencies for the purposes of treatment andcare coordination:

The following information is requested:

o ALL RECORDS

o X-RA YS/SCANS

o RECORDS SPECIFIC TO

For the time period 0(: _

The following information is requested:

o ALL RECORDS

o X-RAYs/SCANS

o RECORDS SPECIFIC TO

o OTHER, _ OOTHER, _

For the time period 0(:, _

I further authorize the Southwest Region Health Care Program for Children with Special Needs,to communicate and correspond with the above named child's (patient) primary care providerand/or office staff for the purposes of treatment and care coordination. This indudes telephone,secure email, fax, or written correspondence.

Name of primary care provider _

I understand that: (1) My signature on this form is strictly voluntary. (2) I may revoke thisauthorization at any time in writing, and if J do it will not have any effect on any actions takenprior to receiving the revocation. (3) If the requester or receiver is not a hea\1h plan or health careprovider, the released information may be disdosed by the recipient and may no longer beprotected by federal privacy regulations. (4) If I do not sign this form, my health care, thepayment for my health care or my abitity to enroll for benefits will not be affected. (5) I mayinspect or obtain a copy of the health information that' am being asked to disdose.Expiration: Without my express revocation, this consent will automatically expire upontermination of services with the Southwest Region Health Care Program for Children withSpecial Needs, but in any event will expire 365 days from the date hereof, unless otherwisespecified.Specified expiration date (optional) _

Signature Date

.-- ,', f •

«,:

I San Juan Board of Cooperative Services.• 201 East 12th St., Durango, CO (970) 247-32611 . .

I Date

legal Name of Child/Student Child/Student ID DOB

Request to Release or Secure Confidential Information(Not required for release to another Administrative Unit.)

Records to be Released or Secured:

Audiometric Medical (Health) Psychiatric

Educational Occupational Therapy Psychological

Speech/Language Physical Therapy Social Work

IEP Other (Specify)

From To

Agency San Juan BOCS San Juan Basin Health

Address 281 Sawyer201 East 12th Street

City, State, Zip Durango, CO 81301 Durango, CO 81301

All information released or secured will be in compliance with the Family Education Rights andPrivacy Act and the Colorado Open Records Law. No additional information will be released orsecured without prior approval from the parent, except as provided by law.

PARENTAL CONSENT

Ihereby authorize the transfer of information as stipulated above Yes No

Signature of Parent(s) Date

Signature of Parent(s) Date

Please send records to HCP Health Care Program for Children with Special NeedsPO Box 140Durango, CO 81302

Fax: (970) 247 -9126

(11) PAGE 1 OF 1

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATIONSOUTHWEST COLORADO MENTAL HEALTH CENTER

Cortez Counseling Center 215 West Arbecam Cortez. CO 81321 970-565-7946 FAX 970-565-9005Crossroads ATU 1125 Three Springs Blvd .. Durango. CO 81301 970-403-0180 FAX 403-0190

Durango Counseling Center PO Box 1328 Durango. CO 81302 970-259-2162 FAX 970-247-5255Pagosa Counseling Center PO Box 1347 Pagosa Springs. CO 81147 970-264-2104 FAX 970-264-2108

New Day PO Box 1328 Durango.CO. 81302 970-259-5820Detox 1125 Three Springs Blvd .. Durango, CO. 81301 970-259-8732

Client Name Client No. Date of Birth----------------------------------- ------------- ----------------I understand there are Colorado and Federal guidelines about my right to confidentiality and protection of my individually identifiablehealth information (CFR 42 Part 2. CRS 25.1, HIPAA). Except in situations legally required or permitted. information about me cannotbe released to persons or agencies outside the treatment team without my written permission. Additional protections exist forsubstance abuse information and for HIV/AIDS status. I hereby authorize SWCMHC and its providers to send, receive, exchange, useor disclose health information about me to:Name/Address/Phone of persons or organizations to receive/release the information:

Particular information to be used or disclosed includes:___ Assessment. diagnosis_ Medication assessments, records_ Update or discharge summaries

Substance abuse data___ Evaluations or testing_ Other (specify) _

The information to be released will be used for the following purposes:__ Continuity of care Additional evaluation or treatment__ Service planning _ Multi-agency coordination

Professional consultation _ Treatment, payment or healthcare operations__ Obtaining basic needs or benefits for the client Vocational serviceNoc. rehabilitation__ At the request of the client or personal representative_ Other (specify} _

_ Legal information_ Social history. background

HIV/AIDS statusEducation informationMedical/lab information

Other important information:1. My treatment by SWCMHC does riot depend on signing this authorization unless treatment is required by a court or other autnorizeu third

party. Some disclosures may be made without my consent if legally permitted or required (see Notice of Privacy Practices for moreinformation).

2. This authorization will expire in one year unless my treatment ends or I revoke it in writing. I may revoke my authorization a any ti.ne.The Center cannot take back any information disclosed before I revoked the authorization.

3. Copies of this form may be used in lieu of the original. Signatures received by fax will be accepted.4. SWCMHC cannot guarantee that recipients of information disclosed through this authorization will not redisclose it to ancther party. The

recipient mayor may not be subject to federal laws protecting health information. If the disclosure concerns substance abuse or HIV/AIOSinformation. the recipient is not permitted to re-release it to anyone.

Client signature Date Witness Signature

If representative, give relation to clientRepresentative Signature

I RENEW THIS AUTHORIZATION FOR USE AND DISCLOSURE OF MY HEALTH INFORMATION FOR ANOTHER 365 DAYS

DateClient signature Witness Signature

Representative Signature If representative. give relation to client

n::ltp

REVOCATION: I revoke my authorization for this use and disclosure of my health information

c ..~O Patient Name MR#->--C t;j Last First MI (completed by TCH).2 Et;j •.• Birth date Phone SS#t:l.<S.s

ParentlGuardianlRequester Completing Form: •Iauthorize The Children's Hospital to Release Medical Record Information to: For the following purpose:

0 Name 5J..n:::JUo.. n &l.sIy) \:ie(il~l)e.pt -)'Ii Continuation of Caref-

:~;o Insurance

Q)

Address POBJX: IYO 0 Legal'" e«!0 Personal Use..2

City/State/Zip h.lfU~ I ~a)~.II) ;)130d 0 Other~

PhoneqlO·atf7 - 'S70;:;"" Fax 9,7Q<:A'f7 -q I ~<aTreatment Dates: From The following fees are

Toapplicable and authorized by

II) Colorado State Law:~ o Pertinent Information (DischargeSummary,H&P, X-Ray,Lab, Surgery,EKG, etc)II)

U o Emergency RoomlUrgent Care o Immunization Record s 14.00 - 1- 10 pages~c o Clinic Information/Notes o Lab Reports ;.,;, s 50lpg - 11- 40 pages.-c o Discharge Summary o Imaging Results o Copy of Images .U,' s .33/pg - each add'l page0 o Complete Medical Record (except ) &!'.~E o Other $150 per page for microfilm'" State/Federal Laws require specific authorization to release the following typescE X-Ray film - $14.00 per sheet.5 of information. Please initial beside the types of information to be released: X-Ray CD - $14.00 per CD

-- HIV/AIDS Related __ Genetic Testing _ Drug/Alcohol abuseMental Health Psychotherapy Notes Sickle Cell Anemia

o Call Requester for pick-up when records are ready. Confirmation of Pick Up:r-; jL Mail records directly to person or organization specified. d,

:9,-CS -. Signatureo Other 'CIS'Q).- E>- I authorize to pick up my Medical Records. Date.- (.)

'iiE ¢:o ~ ,C CD Film

0 - -- Relationshipto patient ·0 _ Checked out Existing Film.--

II)I understand that: (I) My signature on this fonn is strictly voluntary. (2) I may revoke. this authorization at any time in writing,

> and ifI do it will not bave any effect on any actions taken prior to receiving the revocatiofu'Further details may be found in the.~Notice of Privacy Practices. (3) If the requester or receiver is not a health plan or health care provider, the released information may15 be disclosed by the recipient and may no longer be protected by federal privacy regulations. (4) lfldo not sign this form, my healthII)

'" care, the payment for my health care or my ability to enroll for benefits will not be affected. (5) I may inspect or obtain a copy of'theII)fr§ health information that 1am being asked to disclose.tx:.~ Expiration: Without my express revocation, this consent will automatically expire upon ~~faction of the need for disclosure, but in~ "0 any event will expire 180 days from the date hereof: unless otherwise specified:N 0";:: -B 0 If this "box "is checked, the Facility will receive compensation for the use or disclosure of my information.~ ='~<t;

~ 1-cII)

Signature Relationship to patient Date.~c,

Authorization for Disclosure of Protected Health Information

Health InformationMgmtI rCH / 13123 E. 16"' Avenue Box 150 I Aurora, CO 80045720-777-4259 / Fax 720-777-7251Radiology 720·777·8625/ Fax 720-777-7132

=tThe Children's Hospital

~~ :.~;·:~':./v'::::·;;·,;',~"680330 (Rev 9/07)