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Patients or authorized health care providers may request copies of patient health records from Clinica Family Health & Wellness. It may take up to 30 days for Clinica Family Health & Wellness to process and provide copies of the patient’s records. A member of Clinica’s staff will contact you when records are ready.

How to request protected patient health information from Clinica Family Health & Wellness

Clinica patients can request a copy of their medical or dental records at any time. You can also ask that your records be sent to another provider or that your records from another provider be sent to Clinica. Please click the appropriate link below to make a medical records request.

To request records in English, click here.

To request records in Spanish, click here.

FAX NUMBERS MEDICAL CLINICS

• Lafayette Clinic Fax: 720.565.4131
• Gilpin and Nederland Fax: 720.565.4133
• Pecos Clinic Fax: 720.565.4128
• People’s Clinic Fax: 720.565.4132
• Thornton Clinic Fax: 720.565.4129
• Westminster Clinic Fax: 720.565.4130

FAX NUMBERS DENTAL CLINICS

• Lafayette Dental Clinic Fax: 720.206.0454
• Pecos Dental Clinic Fax: 720.206.0437
• Thornton Dental Clinic Fax: 720.207.0171

Clinica Family Health’s Self-pay Policy applies to all patients without medical and/or dental coverage.

All patients who do not have medical or dental coverage will be asked to pay $150 at the time of their visit to see a primary care provider or a dentist.

• Charges for your visit may exceed $150.
• You will receive a bill by mail if you have additional charges from your visit.
• If you are unable to pay the full amount, our billing staff will work with you to set up a payment plan.

Are You Eligible to Save Money on Your Care?

Find out by talking with an Enrollment Specialist at Clinica. Call to schedule a free appointment to meet with us and see how you may be able to save more money on your care. Call 303-650-4460.

Your Responsibilities As Our Patient

FOLLOW CLINICA RULES — Behave respectfully toward Clinica Family Health staff as well as other patients. Please assist with the control of noise and observe the no smoking policy and all other posted building regulations.

INFORM REGARDING YOUR HEALTH — Please give full and honest information regarding your past and present health information, including any known allergies and/or sensitivities.

MEDICATION SAFETY — Please keep and share information on all medications you take, including those from other health care providers, over-the-counter medications and dietary supplements. If you currently take medications, please bring all your medications to each appointment. Many health care mistakes are made because patients don’t tell their health care provider about all the medications they take.

REPORT CHANGES — Report any changes in your condition, symptoms, and allergies to your provider.

REPORT EMERGENCIES — Should you receive emergency care from another health care provider, emergency room, or urgent care center, please contact Clinica during normal business hours as soon as possible to share this information.

PARTICIPATE IN YOUR OWN HEALTH CARE — If you do not understand your provider’s instructions or have any questions, please ask your provider to explain more clearly or ask that someone else assist in explaining the instructions to you.

REPORT SAFETY CONCERNS — We encourage you to help us by reporting any concerns you have about your or your family’s safety at Clinica. Report concerns to a staff member or a manager.

FOLLOW INSTRUCTIONS — Follow the instructions and health care plan that you and your provider have agreed on. Failure to do so may worsen your condition.

MANAGE YOUR TRANSPORTATION NEEDS — If indicated by your provider, make arrangements for a responsible adult to provide transportation home from the clinic and to remain with you as directed.

BE ON TIME — Arrive on time for your appointment.

CANCEL APPOINTMENTS — If you are not able to keep a scheduled appointment, you are required to cancel that appointment prior to the scheduled appointment time. We ask that you cancel with as much advanced notice prior as possible.

SHOW INSURANCE CARD — Show your insurance card, including your Health First Colorado (Medicaid) card, at each visit.

REGISTRATION INFORMATION — Please provide all necessary records as requested.

FINANCIAL SCREENING — Complete the financial screening process by bringing all insurance, income, and other requested information to the enrollment staff within 30 days of your first visit or when your insurance expires. You may be excluded from seeking care at Clinica Family Health if you do not meet with an enrollment staff member to determine program eligibility or self-pay designation.

PAY BILLS — Accept personal financial responsibility for any charges not covered by insurance. Your fees will be adjusted so that they are affordable for you. Please pay all co-pays and bills promptly.

Your Rights As Our Patient

ACCESS — Appointments are provided within a reasonable period of time. Discount programs available for individuals based on family size and income. You will not be denied health care services due to your inability to pay.
Clinica Family Health does not discriminate against any person on the basis of race, color, national origin, disability, religion, gender, gender identity, sexual orientation, or age in admission, treatment, or participation in its programs, services, activities, or employment.

Clinica will make accommodations when requested to provide care in your preferred language. You may request other reasonable accommodations related to any disability you may have. For further information about this policy and other accommodations and non-discrimination policies of Clinica, refer to our Accommodations, Nondiscrimination & Accessibility page on our website.. To contact our 504 Coordinator at 303-665-3036, ext. 1550 or email: 504 Coordinator TDD: 1-800-659-2656

All patients have the right to select their pharmacy of choice, diagnostic imaging and test center(s) and preferred specialist. Patients are under no obligation to use Clinica facilities for these services.

DIGNITY — Care is provided in a manner that respects your individuality and dignity. This includes being told by your care givers what your condition is, what treatment they recommend, how they expect your condition to change, and what follow-up care is needed.

PRIVACY — All physical exams, interviews, and discussions about your health care, including appointment check-ins, will occur privately, and your health records will be handled confidentially. Clinica Family Health will handle all of your records in compliance with federal and state privacy laws (HIPAA) and will abide by the terms of this notice.

EMPLOYEE IDENTIFICATION — You have the right to know the names, professional status, and experience of the staff providing your care.

CONSENT — Consent for treatment will be requested by our medical staff before any procedure is performed. The procedure – as well as its value, risks, and other options for treatment—will be explained.

REFUSAL OF TREATMENT — You have the right to refuse any care recommended. You have the right to change your mind before undergoing a procedure for which you have already given your consent.

ACCESS TO RECORDS — You may review or receive a copy of your medical record within 30 days of your written request. Complaints about access to your records can be addressed to the Colorado Department of Public Health and Environment https://www.colorado.gov/cdphe

BILLS — You have a right to an explanation of all charges and discount program adjustments if you qualify for Clinica’s discount program.

FILE A COMPLAINT OR GRIEVANCE — You have the right to file a complaint if you are not satisfied with any aspect of your care. You can file a complaint using any of the following methods:

Contact Clinica Family Health at 303-650-4460 and ask to “file a complaint”
You may send a complaint or grievance in writing to:
VP of Operations
c/o Clinica Family Health
1735 S. Public Road
Lafayette, CO 80026
You may fill out a Your Comments Count feedback card that can be picked up in the clinic
Contact Health and Human Services at www.HHS.gov.

CHANGE YOUR PROVIDER — You have the right to request a change of provider or clinic if another qualified provider is available. For information about how to request a change of provider or clinic, contact Clinica’s Communication Center at 303-650-4460.

USE OF YOUR HEALTH INFORMATION — Clinica Family Health is permitted to use or disclose your health information for the purposes of treatment or payment, or if the disclosure is required by law and the information released does not include any identifiable information.

Clinica Family Health does not discriminate against any person on the basis of race, color, national origin, disability, religion, gender, gender identity, sexual orientation or age in admission, treatment, or participation in its programs, services and activities, or in employment. Clinica will make accommodations to provide care in your preferred language. For information about this policy and other accommodation and non-discrimination policies of Clinica, review this website or contact our 504 Coordinator:

Phone: 303.665.3036 Ext.1550
TDD: 800.659.2656
Email: 504Coordinator@clinica.org
For information on notice of nondiscrimination, visit:
http://wdcrobcolp01.ed.gov/CFAPPS/OCR/contactus.cfm

For the address and phone number of the office that serves your area call: 800.421.3481.

Clinica Family Health Provides:

Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other format (large print or other formats).

Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact our Communication Center to request assistance at 303.650.4460. If you believe Clinica has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Clinica Family Health, 1735 S Public Rd, Lafayette, CO 80026. You may call 303.665.3036, ext 1550 or (TDD) 800.659.2656. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You may also file a civil rights compliant with the U.S. Department of Health and Human Services, Office of Civil Rights at www.orcportal.hhs.gov; or by mail at U.S. Department of Health and Human Services, 200 Independence Ave, SW Room 506F, HHH Building Washington, DC 20201; or by phone at 800.368.1019 or (TDD) 800.537.7697.

Clinica’s 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, a record of your visit is created. 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, such as from health plans, Medicaid, or you; and
• Our community health center to measure the quality of care provided to you.

As we have in the past, we are committed to keeping your health information confidential. We will not use or give to others 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 give out 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 give your health information to health care professionals not on our staff, such as other doctors and hospital staff, who help care for you. This information may be shared via fax, paper or electronic formats.
• Clinica Family Health endorses, supports, and participates in an electronic Health Information Exchange (HIE) as a means to improve the quality of your health and healthcare experience. The Colorado Regional Health Information Organization (CORHIO) HIE provides us with a way to securely and efficiently share patients’ clinical information electronically with other physicians and health care providers that participate in the HIE network. Using HIE helps your health care providers to more effectively share information and provide you with better care. The HIE also enables emergency medical personnel and other providers who are treating you to have immediate access to your medical data that may be critical for your care. Making your health information available to your health care providers through the HIE can also help reduce your costs by eliminating unnecessary duplication of tests and procedures. However, you may choose to opt-out of participation in the CORHIO HIE, or cancel an opt-out choice, at any time. To opt-out of the CORHIO HIE, please request the necessary paperwork from a front desk employee at any of our clinics.
• The Colorado Immunization Information System (CIIS) is a confidential, computerized, population-based system that collects and consolidates immunization data for Coloradans of all ages from a variety of sources and provides tools for designing and sustaining effective immunization strategies to prevent disease and reduce healthcare costs. Clinica Family Health participates in CIIS so that we are able to see the vaccines that you/your child received in the past as well as any vaccines recommended for you/your child at the time of the visit. Clinica Family Health can print immunization forms needed for child care, school and camp enrollment directory from the secure CIIS web application. However, you may choose to opt-out of participation in CIIS, or cancel an opt-out choice, at any time. To opt-out of CIIS, please request the necessary paperwork from a front desk employee at any of our clinics.
• We have formed an organized health care arrangement (OHCA) with Mental Health Partners and Dental Aid to better address your health care needs. The OHCA members will use your health information in an integrated care setting where you may receive health care services from more than one provider. The OHCA members will work together in utilization review, quality activities, and/or payment activities.
• We may send a bill to your health insurance plan or to you; and
  Our community health center may use your medical record to review our performance and make sure you receive quality health care.

b. OTHER USES AND DISCLOSURES ALLOWED OR REQUIRED BY LAW

We may use or give out 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, such as your family, your 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);
• To government agencies that have the right to receive and collect health information (such as to control disease outbreaks);
• 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 coroners and funeral directors to allow them to carry out their duties;
• To organ donor agencies (subject to applicable laws);
• To avoid a serious threat to the health or safety of others;
• To contact you about new treatments or medicines that may help you.
• For the purpose of research, only under limited circumstances.
• To business associates of the community health center that help us perform required tasks, such as our accountants, computer consultants, and billing companies (only if the business associate agrees in writing to keep your health information confidential as required by law); and
• For any other purpose required or allowed 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 getting 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.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

• Psychotherapy Notes – Although we do not anticipate maintaining your psychotherapy notes, in the extent that we do maintain such psychotherapy notes, use and disclosures of such notes, with limited exception.
• Marketing – Uses and disclosures of your protected health information for marketing purposes.
• Sale of Protected Health Information – Any disclosure of your protected health information that would result in remuneration to us. Such disclosures will be made only in accordance with your authorization.

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 rights to:

• Request limits on uses of your health information
• Receive confidential communications of your health information
• Inspect and copy your health information
• Request a change to your health information
• Receive a record of how we have used and given out your health information
• Obtain a copy of this Notice of Privacy Practices
• Right to Receive an Electronic Copy or your Electronic Protected Health Information – If you request an electronic copy of your protected health information (including electronically linked information) that we maintain in an electronic designated record set, you have the right to be provided with access to that electronic information in the form or format that you request, if it is readily producible by us in the requested form or format. If the electronic information is not readily producible in your requested form or format, we will provide the electronic information in a form or format to which we agree. If you reject the form or format of electronic information that we are able to produce, we will provide a hard copy of the information to you. If we maintain your information in mixed media format (electronic and hard copies), we will provide you with a copy of your information in that same mixed media format. If you request that we provide your electronic information in an unencrypted format (e.g. unsecure email), we will require your agreement to the risks of such transmission. If you so request, we will transmit your electronic information to a third party designated by you. A fee will be charged for the costs of providing copies of your medical record.
• Right to Receive Notice of Breach – You have the right to receive notice from us of a breach of your unsecured protected health information.
• If you are deceased, we may disclose information after your death to your next of kin.
• Right to Request Restrictions – You have the right to request a restriction or limitation of the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a clinic visit you had. We are required to agree to your request only if 1) except as otherwise required by law, the disclosure is to your health plan and the purpose is related to payment or health care operations (and not treatment purposes), and 2) your information pertains solely to health care services for which you have paid in full, out of pocket. However, we are not required to comply with your request if your payment is not honored, or for other services that may be related to or in follow up to the services for which you have paid in full, if you did not also pay for these additional services in full. For other requests, we are not required to agree. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the clinic’s 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, for example, disclosures to your spouse.
• Health Plans or Health Insurer’s may not use or disclose genetic information for underwriting purposes. There is an exception for underwriting performed by issuers of long-term care policies.

IV. QUESTIONS, CONCERNS, AND CHANGES TO THIS NOTICE

If you have any questions or want to talk about any of the information in this Notice of Privacy Practices, please contact the HIPAA Privacy Officer at 1345 Plaza Court N. Suite 1A, Lafayette, CO. (303) 650-4460.

If you believe your privacy rights have been violated, you may file a complaint with our community health center or with the Secretary of the Department of Health and Human Services. To file a complaint with our community health center, submit it to the HIPAA Privacy Officer at 1345 Plaza Court N. Suite 1A, Lafayette, CO 80026. All complaints must be submitted in writing. We will not retaliate against you for filing a complaint.

We may change our Notice of Privacy Practices in the future. Such changes will apply to your health information that we created or received before the effective date of the change. We will notify you of any changes to our Notice of Privacy Practices by posting the changed notice at our community health center. In addition, at any time you visit the clinic, you may request a copy of the most recent privacy notice, and it will be provided to you.

We Welcome Your Feedback

We are always looking for ways to improve the care we provide to our patients. Whether you have a new idea for us to try or feedback on an experience at any of our locations, we want to hear about it. Click the link below to open our Patient Experience Form. It will automatically be sent to a senior member of our staff for review and determine how to best address the information. The appropriate person on staff will respond to your feedback within 72 hours. Patient Experience Forms are also available in each clinic. Any staff member can get you a form and help you complete it.

Thank you for helping us make Clinica Family Health a better community health center.

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