NOTICE OF PRIVACY PRACTICES
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.

I. UNDERSTANDING YOUR HEALTH INFORMATION
Each time you visit our community health center, we create a record of your visit. This record usually contains your name and other information that may identify you, your symptoms, examination and test results, diagnoses, treatment, plan for future health care, and financial information. This record is sometimes referred to as your “medical record” or “medical chart.” This record allows:

• Doctors, nurses, and other health professionals to plan your treatment;
• Our community health center to obtain payment for services we provide to you from health plans, Medicaid, or you; and
• Our community health center to measure the quality of care provided to you.

As in the past, we are committed to keeping your health information confidential. We are required by law to maintain the privacy of your health information and to inform you of our legal duties and privacy practices with respect to your health information. We are required to abide by the terms of this notice, although we reserve the right to change the terms of this notice and will provide you with a revised version via or websites or in person should the terms change. You may request a copy of the current notice at any time. We will not use or share your health information without your written permission, except as stated in this notice.

II. HOW WE WILL USE AND GIVE OUT YOUR HEALTH INFORMATION
A. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
We will use and share your health information to provide you with health care treatments, to get paid for our services, and to help us operate our community health center. For example:
We will share your health information with health care professionals not on our staff, such as other healthcare providers and hospital staff, who help care for you. This information may be shared via fax, paper or electronic formats. We also participate in an organized health care arrangement and a health information exchange (Colorado Regional Health Information Organization or CORHIO) that enables healthcare providers to share a database containing your health information for treatment purposes and enables the delivery of better, more efficient care to you. However, you may opt out of participation in CORHIO at any time by notifying our staff, who will then provide you with the forms to do so.
We may send a bill to your health insurance plan or to you to obtain payment for services rendered.
We may use your medical record to review our performance and make sure you receive quality health care and/or to conduct training or compliance functions/activities.

B. OTHER USES AND DISCLOSURES ALLOWED OR REQUIRED BY LAW
We may use or disclose your health information for the following purposes under limited circumstances:

• To people who are involved in your care or who help pay for your care (e.g., your family, close personal friends, or any other person chosen by you) to notify them of your location, general health, and to assist you in your health care (such as to pick-up medicine or help with follow-up care);
• To government agencies that oversee our community health center (such as license and certification inspectors), and/or for specialized government functions, such as military and veteran’s activities, national security and intelligence activities, and protection of public officials;
• To government agencies that have the right to receive and collect health information (such as to control disease outbreaks). We also share health information with the Colorado Immunization Information System (CIIS), which is a confidential database housing immunization data for Coloradans. You may opt out of participation in CIIS at any time by notifying our staff, who will provide you with the forms to opt out;
• When we are ordered by a court or judge;
• To workers’ compensation programs when your health problem is from a work-related injury;
• When law enforcement requests information (such as to prevent danger or injury);
• To report information related to victims of abuse, neglect, or domestic violence or other public health-related permitted uses or disclosures;
• To coroners and funeral directors to allow them to carry out their duties upon your death, and/or for cadaveric organ, eye, or tissue donation and transplantation purposes;
• To organ donor agencies (subject to applicable laws);
• To avoid a serious threat to the health or safety of yourself or others;
• To notify or assist in notifying your family, a personal representative, another person responsible for your care, or disaster relief authorities of your location, condition, or death.
• To contact you about appointment reminders, new treatments, or medicines that may help you;
• For the purpose of research under limited circumstances;
• Through business associates or other contractual arrangements. Some services in our organization are provided through contracts and/or agreements with business associates and other healthcare organizations. Examples include physician services in the emergency department and radiology, mental health services, laboratory and diagnostic services, and other organizations who help to improve the quality of your health and healthcare experiences or assist with our back-office operations (e.g., billing, information technology, etc.). When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do. So that your health information is protected, we require business associates to safeguard your information appropriately.
• We may use medical information about you to contact you in an effort to raise money for the clinic and its operations. If you are contacted in our fundraising efforts, you will have the opportunity to opt out of receiving further fundraising communications from us.
• For any other purpose required or permitted by law.

C. OTHER USES AND DISCLOSURES REQUIRING YOUR WRITTEN PERMISSION
Except as stated above, we will use or give out your health information only after obtaining your written permission on an authorization form. You may revoke your authorization at any time by notifying us in writing that you wish to do so.

III. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Subject to certain legal limits, you have rights regarding the use and disclosure of your health information, including the right to:
Request limits or restrictions on uses of your health information in certain circumstances. However, we are not required to comply with requests in all cases. To request restrictions, you must make your request in writing to Clinica’s HIPAA Privacy Officer. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply.

• Receive confidential communications about your health information.
• Inspect and copy your health information.
• Request a change or amendment to your health information.
• Receive a record or accounting of how we have used or disclosed your health information.
• Obtain a copy of this Notice of Privacy Practices.
• You have the right to receive notice from us of a breach of your unsecured protected health information.

IV. QUESTIONS, CONCERNS, OR COMPLAINTS
If you have any questions or wish to discuss any of the information in this Notice of Privacy Practices, please contact the HIPAA Privacy Officer at 1735 S. Public Rd., Lafayette, CO, 80026. You can also call our HIPAA Privacy Officer at (303) 650-4460.

If you believe your privacy rights have been violated, you may file a complaint with our community health center or the Secretary of the Department of Health and Human Services. To file a complaint with our community health center, submit a written statement to the HIPAA Privacy Officer at 1735 S. Public Rd., Lafayette, CO, 80026. For information on how to file a formal HIPAA privacy complaint directly with the Department of Health and Human Services go to: https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html. We will not retaliate against you for filing a complaint.

Pricing for the 15 most common services we provide

Colorado Law requires us to post the full-fee price for the 15 most common services we provide. These are not necessarily the actual prices you will end up paying.*

The prices listed below are an estimate of what you might pay if:

• You do not have insurance (including Medicaid and Medicare);
• The service isn’t covered by your insurance; or
• You are not enrolled in Clinica’s Discount Program or other program offered at Clinica Family Health.

Most people who receive the services noted below at Clinica do not pay the prices listed.

GOOD FAITH ESTIMATES FAQs

What is the new requirement?

Beginning on Jan. 1, 2022, all community health centers and most other health care providers must give all uninsured or self-pay patients an estimate of the cost of their care prior to their appointment. This mandate comes from the federal No Surprises Act, which was passed in December 2020. These cost estimates, also called Good Faith Estimates (GFEs), summarize a patient’s total out-of-pocket expenses for the care they will receive at the specified appointment. GFEs must be provided to qualifying patients who schedule an appointment at least three business days in advance or to any patient specifically requesting a GFE.

Are GFEs optional?

Patients cannot opt out of these estimates, and Clinica must provide them.

Which patients must be provided a GFE?

All uninsured and self-pay patients must be provided a GFE for their visit as long as they:

• Schedule an appointment for that service at least three business days in advance.
• Request a GFE (or otherwise ask about the costs of the service) even without scheduling an appointment.
• Have insurance but it does not cover the service they are seeking (e.g., they only have medical coverage but are inquiring about a dental service).
• Have a short-term, limited-duration plan.
• Are underinsured and indicate that they do not plan to submit a claim to their insurer but will pay for the service entirely out-of-pocket.

What information is included in the GFE?

A GFE must provide the following information:

• The primary service being provided to the patient during the visit or “period of care.”
• The items and/or services that are “reasonably expected” to be provided “in conjunction with the primary service” for which Clinica, or an outside provider, has a separate charge. For example, if a patient schedules an appointment for suspected strep throat, the GFE would include an office visit, a lab test (if there is a separate charge for that) and a generic medication.
• The exact charge for the service(s) the patient will be receiving related to the appointment.

The services listed on the GFE will be based on the information available at the time it is requested or generated. The GFE is not required to cover unanticipated care that is not reasonably expected or results from unforeseen events.

What is the “period of care” for a GFE?

In most cases, the “period of care” is a single day. However, if a patient receives a single service that requires returning to the clinic to receive full service (e.g., the two-dose HPV vaccine), then the period of care should encompass both dates. Also, if the patient will have lab work done on a different day and those services are scheduled by Clinica, then the period of care must include both dates.

What if the cost of an item or service is incorrect on my GFE?

Patients whose charges are more than $400 above the cost estimate can pursue a dispute resolution process to get their charges reduced. To pursue a dispute resolution, contact our Billing Department at (303) 827-7102.

Will Clinica staff be required to ask me if I am uninsured or self-pay to determine if I should receive a GFE?

Yes. The new federal law requires that health care providers, or a member of their team, ask every person who schedules an appointment (or asks about the cost of their care) if they are:

• uninsured for that service
• are self-pay (they do not plan to submit a claim or their insurance doesn’t cover the service)

How will I receive my GFEs?

You will receive GFEs through the patient portal or by standard mail (US Postal System). All GFEs will be stored in the patient’s chart for six years for future reference.

Can I ask for a GFE during an appointment?

If you ask ask for a cost estimate at the time of service, you will be directed to Clinica’s Billing Department at (303) 827-7102.

What if I have questions about my GFE?

If you have additional questions after receiving their GFE, you can contact the Billing Department at (303) 827-7102.

Must costs for dental and vision services (e.g., dentures, glasses frames, lenses, etc.) be included in the GFE?

Yes. GFE rules apply to “items or services such as those related to dental health, vision, substance use disorders and mental health.”

FAX NUMBERS FOR OUR CLINICS

Alpine: 720-206-0441

Gilpin: 720-565-4134

Lafayette: 720-565-4131

Nederland: 720-565-4133

Pecos: 720-565-4128

People’s: 720-565-4132

Thornton: 720-565-4129

Westminster: 720-565-4130