Welcome to the Springfield Family Physicians Family! · Pearl Street Provider Jillian Miller, PA-C Marcola Road Clinic: 2280 Marcola Rd / Springfield, OR 97477 - Centennial Blvd Clinic:

Marcola Providers Jeffrey Beckwith, MD Caroline Coulter, DO

Jennifer Durrant, FNP-C Lana Gee-Gott, MD

Robyn Gilbertson, MD Meredith Karns PA-C

Mark Meyers, MD Emily Saunders, PA-C Elizabeth Stover, MD

John White, MD

Centennial Providers Yumi Aikawa, DO

Katherine Cawthorn, PA-C Nandish Dayal, FNP Ashley Marreel, DNP

Jordan Moon, PA-C Dan Paulson, MD

Jenae Ulrich, Psy.D Benji Smith, PA-C

Timber Valley Providers

Alejandro Colmenero, PA-C Doherty Gilchrist, MD

Pearl Street Provider Jillian Miller, PA-C

Marcola Road Clinic: 2280 Marcola Rd / Springfield, OR 97477 - Centennial Blvd Clinic: 1800 Centennial Blvd / Springfield, OR 97477 Timber Valley Medical Clinic: 21 Hayden Bridge Way, Springfield, OR 97477 Pearl Street Clinic: 1501 Pearl St / Eugene, OR 97401

Phone: 541-747-4300 / Fax: 541-747-0655 / Business Office: 541-747-8576 www.SpringfieldFamilyPhysicians.com

Welcome to the Springfield Family Physicians Family!

We are honored that you have chosen us as your healthcare provider and are excited to welcome you as a new patient! We value all of our patients and are committed to providing accessible, affordable, high-quality medical treatment to you and your family in a timely, caring and compassionate manner.

Thank you for scheduling your first appointment with our practice. We look forward to working with you to help you and your family stay happy and healthy. Prior to your first appointment, please complete the attached new patient paperwork. Please bring the completed paperwork to your first appointment, along with a current insurance card and photo ID. On the day of your first appointment, please arrive ten minutes prior to your scheduled appointment time for check in.

Also included in your new patient information packet is a brochure for our online patient portal. We believe that managing your health is a partnership between you and your healthcare team, and the patient portal is an important tool in that partnership. With the online patient portal and the convenient smartphone app, you can access your healthcare information, communicate with office staff, and request appointments from the comfort of your home.

If you have any questions, or wish to sign up for the online patient portal, please contact our office staff at (541) 747 4300.

Thank you, The Springfield Family Physician Staff

http://www.SpringfieldFamilyPhysicians.com


Patient (print): Date of Birth:Last First MI mm/dd/yyyy

Address:Street City State Zip

SSN: Sex: M F Single Married Widowed DivorcedHome #: Cell #: E-mail Address:Employer:

Name Address

Spouse/Partner Name: Date of Birth: SSN:Employer: Work #:

Name AddressNotify this person in case of emergency? Yes NoIf no, who should we notify? Phone #:Local relative/friend not living with you:

Name Relationship PhoneAddress:Person responsible for payment: Self Other: Relationship:Address of responsible party (if other than above): Home #:Employer of responsible party: Work #:

Whom may we thank for referring you to our practice? Assigned by insurance company or OHP Referred by: Advertisement (where): Insurance company list Yellow Pages

Primary Insurance Company: Effective Date:Billing Address: Phone #:Group Number: ID #:Insured Name: DOB: Who is covered on the plan?Secondary Insurance Company: Effective Date:Billing Address: Phone #:Group Number: ID #:Insured Name: DOB: Who is covered on the plan?

The undersigned patient or responsible party authorizes the physicians of Springfield Family Physicians, as well as other physicians who may be consulted regarding medical advice and treatment, to provide any medical or surgical care which, in the opinion of the physician(s), may be reasonably necessary for the benefit of the patient’s care. The undersigned further authorizes Springfield Family Physicians to use and disclose medical information regarding the patient’s treatment, payment of medical expenses, or to carry on the operations of the clinic, as necessary for care of the patient. Signing below indicates that a copy of our Privacy Policy was offered and received or refused, as indicated by the initials of the patient or responsible party. I understand that I am financially responsible for all charges for the services rendered to me. I authorize release of information necessary to process my insurance claim. A photocopy of this authorization may be used in place of the original. I hereby suthorize payment of benefits due to me to be made directly to the doctor or provider of services. I understand that some charges may be denied by Medicare and I will be responsible for payment with a signed advanced beneficiary notice.

Patient or Responsible Party Signature: Date:Relationship if signed by Responsible Party:Privacy Policy Received: Date: Privacy Policy Offered and Refused: Date:

Patient/Resp. Party Initials: Staff Initials:

Patient Information This form must be completed in full


Marcola Road Clinic: 2280 Marcola Rd / Springfield, OR 97477 - Centennial Blvd Clinic: 1800 Centennial Blvd / Springfield, OR 97477Timber Valley Medical Clinic: 21 Hayden Bridge Way, Springfield, OR 97477 Pearl Street Clinic: 1501 Pearl St / Eugene, OR 97401

Work #: Do you have access to the internet? Yes No



Personal Habits: (Update Annually)• Exercise (type and how often):• Work: Hours/Day Indoors or Outdoors• Do you enjoy your work? Yes No• Participate in Sports/Hobbies? Yes No• Caffeine (coffee/soda)? Yes No # cups/day• Number of hours of sleep per night:• Do you have any safety issues at home? Yes No

Patient Name (Please Print): Date of Birth:Occupation: Previous Occupations:Date of Last Examination: Marital Status: Married Single Separated Divorced Domestic Partner Widowed

Personal History: (Update Annually)ALLERGIES TO MEDICATIONS:1.2.3.4.

MEDICATIONS: List all, including over-the-counter1.2.3.4.5.6.7.8.

HOSPITALIZATIONS & SURGERIES: Year1.2.3.4.5.6.7.8.9.10.

Immunization History:Pneumonia Vaccine: Yes No Date:Tetanus shot within 10 years: Yes No Date:

Personal and Family History:If applicable, please note WHO has had problem and AGE at onset (Self, parents, children, brothers, sisters grandparents, aunts, uncles)

SELF WHO AGE

If deceased, age at death:Alcoholism: Anemia:Asthma:Cancer or Tumor:Clotting/Bleeding Problems:Diabetes:Epilepsy:Gout:Heart Problems:High Blood Pressure:Mental Illness/Depression:Rheumatism or Arthritis:Stroke:Thyroid Problems:Other:

Please list any problems you are having at this time:1.2.3.4.Do you have a Living Will/Advanced Directive?

Yes NoIf not, would you like to discuss this with your doctor?

Yes NoRoutine Checkup - No Problems

Medical History Form (Please complete entire form before your visit) Today’s Date:

• Alcoholic beverages? Yes No If yes, what type and how many drinks daily?• Have you ever been treated for alcoholism? Yes No• Have you ever been treated for drug abuse? Yes No• Have you ever used “recreational” drugs? Yes No

If yes, what type, how often and last date?• Tobacco: Cigarettes Yes No # packs/day Cigars Pipe Chewing Tobacco Snuff• If you have smoked in the past, when did you quit?

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes NoYes No

Yes NoYes NoYes NoYes NoYes No

Personal History continued: For annual exam, please update informationPlease mark an X in the appropriate blank spaces Have this problem now Had this problem in the past 1. Stiffness or pain in muscles or joints2. Swollen joints or arthritis3. Back or shoulder pain4. Pain in your feet5. A physical disability6. Skin problems7. Changing moles or skin spots8. Trouble stopping cuts from bleeding9. Unexplained bruises or sores that don’t heal10. Fainting, dizziness or light headed feelings11. Numbness12. Seizures or convulsions13. Shakiness or trembling14. Significant headaches15. Death of a family member this year16. Sleep problems or insomnia17. Nervousness, anxiety, irritability or anger18. Problems with memory or concentration19. Feelings of loneliness or depression20. Sexual problems21. Any suicidal thoughts22. Gained or lost over 10 pounds recently23. Appetite problems24. Overly thirsty25. Feelings of being too hot or too cold26. Heartburn27. Bloating or belching after eating28. Nausea or vomiting29. Constipation30. Diarrhea or loose stools31. Bleeding from the rectum or black stools32. Frequency with urination in the day or night33. Difficult or painful urination34. Urinate when you cough or sneeze35. Brown or red colored urine36. Eye problems, blurred or worsening vision37. Hearing problems38. Tooth pain or lumps in your mouth39. Sneezing, stuffy nose, congestion in nose40. Cough, wheezing or difficulty breathing with exertion41. Nighttime shortness of breath; use pillows to breathe42. High blood pressure43. Heart palpitations, irregular or racing heartbeat44. Chest pain or pressure45. Heart Murmur

FOR MEN ONLY:46. Swelling, lumps or pain in your penis/testicles47. Prostate problems, slow or weak urine stream48. Burning or discharge from your penis49. Last Colonoscopy: Date Where:

FOR WOMEN ONLY:49. Hysterectomy50. Began having menopause symptoms51. Vaginal discharge or pain52. Irregular menstrual periods53. Lumps or pain in your breasts54. What was the date of your last menstrual period? 58. Date of Colonoscopy Date Where55. When was your last pap test? 59. Last Mammogram Date Where56. Number of pregnancies 60. Birth Control Method?57. Number of live births 61. Have you ever had an abortion?

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes NoYes No

Yes NoYes NoYes NoYes NoYes No

Note: This confidential record of your medical history will not be released without your written permission.

Personal History continued: For annual exam, please update informationPlease mark an X in the appropriate blank spaces Have this problem now Had this problem in the past


Phone: 541-747-4300 / Fax: 541-747-0655 / Business Office: 541-747-8576

Springfield Family Physicians Financial Policy Thank you for choosing Springfield Family Physicians as your primary care provider! Our staff is committed to providing our patients with quality and affordable healthcare. Part of this care includes your responsibilities as a patient to understand the financial obligations. Your care is a team effort, and you and our staff work together with both finances and treatment to ensure you a healthy, and happy life. Please read and sign this financial policy form, and return it to the receptionist with any questions you may have.

Patient Information: • All patients at Springfield Family Physicians must fill out a patient information form and sign a copy

of this form. We will also scan copies of your driver’s license and insurance card into an online file.• Our fees represent the current and customary fees and prices of offices in our area.• Charges for minors will be billed to the guardian parent. We will not bill the non-custodial parent on

behalf of the custodial parent. If the child is listed on the appropriate insurance information, we willbill insurance.

• Dependents 18 years and older will be placed on their own account.

Insurance Information: • Our office will submit claims to insurance companies and assist patients in any reasonable way with

insurance claims.• In order to provide patients with this service, our office needs all insurance information. If adequate

information is not provided, the patient is responsible for the payment and will be billed in full• If the patient believes they may be covered by a secondary insurance, and provide all information of

secondary insurance, we will submit a claim as a courtesy to the patient. The responsibility of the billremains with the patient until it is paid

• Our office participates in many insurance plans. As a part of these plans, our fees are contracted andmay change. Our participation with these programs is also subject to change. Patients must verifyour participation with their plans at the time of their visit. Changes in participation will be posted atthe front desk.

• If insurance has not paid within 60 days, the bill becomes the responsibility of the patient. It is alsothe patient’s responsibility to dispute any insurance claims with the insurance company

• It is the patient’s responsibility to know their insurance benefits. Patients will be billed for servicesnot covered by insurance

• It is the patient’s responsibility to notify our office of insurance changes and provide updated proofof insurance

I have received and read the Financial Policy for Springfield Family Physicians. I understand my responsibilities as a patient, including providing the practice with insurance information, understanding my insurance benefits, and payment of my account. If it becomes necessary to transfer my account to collections, I agree to pay all associated costs and fees. I have received a copy of this policy for my records.

Patient Signature: _______________________________________

Patient Name (Printed): _____________________________________________________________

(Continued on Back)

www.SpringfieldFamilyPhysicians.com





John White, MD





Timber Valley Providers Alejandro Colmenero, PA-C

Doherty Gilchrist, MD


Date: _________________

Patient Responsibility for Payment: • Co-payments, co-insurance, and charges that apply to your deductible are due at time of service.Insurance companies require that we collect your co-pay at time of service. We do not bill for co-pays.If you are unable to pay your co-pay, we may reschedule your appointment. Three missed co-pays mayresult in dismissal from our practice.• If you pay in full for services not covered by insurance on the date of service, you will receive a 12%discount. This does not apply to co-payments or deductibles required by your insurance company.• If you are unable to pay and have a good credit history with our office, we may allow you to pay forservices on a financial agreement. Reasonable and timely monthly payments are expected. Missing apayment means that you have broken the contract with us and may result in referral to a collectionagency and/or dismissal from the practice. We allow one financial agreement at a time per family. Theoriginal agreement must be paid in full before another agreement may begin. Additional services willnot be added to an existing financial agreement. New patient charges may not be paid on a financialagreement.• If you are on a payment plan or have had payment issues in the past, we will place your account on“Cash Pay” terms. This means we will require payment of a deposit before you see the doctor.• We accept payment by cash, check, VISA, MasterCard or Discover card. We do not hold checks oraccept post-dated checks.

Billing: • You will receive a monthly statement listing all services, payments and adjustments, and noting thedate your insurance was billed. The statement will specify an amount due from you, and payment isdue upon receipt.• A late fee of 18% APR, with a minimum monthly charge of $5, will be added to patient due balancesthat are outstanding over 30 days.• If you have no insurance coverage and have difficulty paying for medical care due to limited income,you may apply for our financial hardship policy. Please ask our receptionist for information.

Non-Payment: • If you do not pay the patient due portion of your bill, our collection analyst will send you a letterstating you must pay within a specified period of time. You must contact us if you would like todiscuss payment arrangements. Please be aware that failure to pay will result in referral to a collectionagency, which may your credit rating.• If we refer your account to a collection agency, you will be charged for all costs and expensesincluding a $50 collection fee, and any reasonable attorney fees.• Referral to a collection agency may result in dismissal from our practice.

Services from Other Providers: • You may have additional medical services ordered by your doctor, such as laboratory or pathologytests, x-rays, or other radiology tests. Our clinic may draw your blood, or take a sample, and send it toanother provider. You will receive a separate bill from that provider for their services. You must makeyour own arrangement for payment with providers outside our office.


Phone: 541-747-4300 / Fax: 541-747-0655 / Business Office: 541-747-8576

Authorization for Release of Medical Records

I authorize: _______________________ (Name of person/entity disclosing information)

to use and disclose a copy of the specific health information described below regarding: _________________________________________ (Name of individual) consisting of: (Describe information to be used/disclosed)

________________________________________________________________________________________________________________________________________________________________________________________________ to:______________________________________________________________ (Name and address of recipient or recipients) for the purpose of: (Describe each purpose of disclosure or indicate that the disclosure is at the request of the individual) ______________

________________________________________________________________ ________________________________________________________________ ________________________________________________________________

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed if I place my initials in the applicable space next to the type of information.

______ HIV/AIDS information ______ Mental health information ______ Genetic testing information ______ Drug/alcohol diagnosis, treatment, or referral information.

I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol diagnosis, treatment or referral information.

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www.SpringfieldFamilyPhysicians.com





John White, MD





Timber Valley Providers Alejandro Colmenero, PA-C

Doherty Gilchrist, MD


You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure.

You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage. To revoke this authorization, please send a written statement to __________________ _____________(contact person) at __________________________________________ ____________________________________(address of person/entity disclosing information)

and state that you are revoking this authorization.

I have read this authorization and I understand it. Unless revoked, this authorization Expires ___________________ (insert either applicable date or event). By: ______________________ (individual or personal representative) Date: _____________________

Description of personal representatives authority: ___________________________________________________________________ ___________________________________________________________________ ____________________________________________________________________





John White, MD





Timber Valley Providers

Alejandro Colmenero, PA-C Doherty Gilchrist, MD




Notice of Privacy Practices Receipt

Our Notice of Privacy Practices (NPP) provides information on how our practice may use and/or disclose protected health information about you for treatment, payment, and health care operations. A copy of our NPP can be found at www.SpringfieldFamilyPhysicians.com and at the check-in desk.

I acknowledge that I have received a copy of Springfield Family Physicians Notice of Privacy Practices. Patient’s Name:(print)

Patient’s Signature: (signature)

Today’s Date

Patient’s Date of Birth

If signed by a personal representative:

Name of Personal Representative: (print)

Signature of Personal Representative: (signature)

Relationship to Patient

Driver’s License Number State

Today’s Date

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

For practice use only: Patient’s ID/Chart Number Signature of Employee Date




We may use and share your information as we:

• Treat you• Run our organization• Bill for your services• Help with public health and safety issues• Do research• Comply with the law• Respond to organ and tissue donation requests• Work with a medical examiner or funeral director• Address workers’ compensation, law enforcement,

and other government requests• Respond to lawsuits and legal actions

➤ See pages 3 and 4for more informationon these uses anddisclosures

You have the right to: • Get a copy of your paper or electronic medical record• Correct your paper or electronic medical record• Request confidential communication• Ask us to limit the information we share• Get a list of those with whom we’ve shared

your information• Get a copy of this privacy notice• Choose someone to act for you• File a complaint if you believe your privacy

rights have been violated

➤ See page 2 formore information onthese rights and howto exercise them

Our Uses and

Disclosures

Your Rights

➤ See page 3 formore information onthese choices andhow to exercise them

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition• Provide disaster relief• Include you in a hospital directory• Provide mental health care• Market our services and sell your information• Raise funds

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Information. Your Rights.Our Responsibilities.

Your Choices

Notice of Privacy Practices • Page 1

Springfield Family PhysiciansMarcola Road Clinic: 2280 Marcola Rd / Springfield, OR 97477 Centennial Blvd Clinic: 1800 Centennial Blvd / Springfield, OR 97477Timber Valley Medical Clinic: 21 Hayden Bridge Way, Springfield, OR 97477 Pearl Street Clinic: 1501 Pearl St / Eugene, OR 97401


When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Your Rights

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record andother health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrector incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone)or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment,payment, or our operations. We are not required to agree to your request, and wemay say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not toshare that information for the purpose of payment or our operations with your healthinsurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health informationfor six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, andhealth care operations, and certain other disclosures (such as any you asked us tomake). We’ll provide one accounting a year for free but will charge a reasonable,cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed toreceive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legalguardian, that person can exercise your rights and make choices about your healthinformation.

• We will make sure the person has this authority and can act for you before we takeany action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using theinformation on page 1.

• You can file a complaint with the U.S. Department of Health and Human ServicesOffice for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.


In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising: • We may contact you for fundraising efforts, but you can tell us not tocontact you again.

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

Your Choices

Treat you • We can use your health information andshare it with other professionals who aretreating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

• We can use and share your healthinformation to run our practice, improveyour care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

• We can use and share your healthinformation to bill and get payment fromhealth plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Our Uses and

Disclosures

continued on next page


Help with public health and safety issues

• We can share health information about you for certain situations such as:• Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence• Preventing or reducing a serious threat to anyone’s health or safety

Do research • We can use or share your information for health research.

Comply with the law • We will share information about you if state or federal laws require it,including with the Department of Health and Human Services if it wants tosee that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

• We can share health information about you with organ procurementorganizations.

Work with a medical examiner or funeral director

• We can share health information with a coroner, medical examiner, or funeraldirector when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

• We can use or share health information about you:• For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law• For special government functions such as military, national security, and

presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court oradministrative order, or in response to a subpoena.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.


Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or securityof your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can inwriting. If you tell us we can, you may change your mind at any time. Let us know in writing if youchange your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This Notice of Privacy Practices applies to the following organizations.

September 23, 2013

Springfield Family Physicians 541-747-4300Marcola Road Clinic: 2280 Marcola Rd / Springfield, OR 97477 Centennial Blvd Clinic: 1800 Centennial Blvd / Springfield, OR 97477Timber Valley Medical Clinic: 21 Hayden Bridge Way, Springfield, OR 97477 Pearl Street Clinic: 1501 Pearl St / Eugene, OR 97401

Documents

Welcome to the Springfield Family Physicians Family! · Pearl Street Provider Jillian Miller, PA-C Marcola Road Clinic: 2280 Marcola Rd / Springfield, OR 97477 - Centennial Blvd Clinic: