NEW Registration packet

2055 W. 12th Avenue. Eugene OR 97402 Phone (541) 484‐‐‐6558 Fax (541) 484‐‐‐0891
CLINIC REGISTRATION INSTRUCTIONS
Please read this important information carefully
All patients must complete a registration packet.
These forms are part of your permanent patient record with Compassion Center Clinic. Please read this
registration thoroughly and be sure to answer each question as completely and as accurately as possible.
Complete the below registration forms, sign and return to Compassion Center along with a copy of your
Driver’s license, state or military ID, or passport and the $25 registration fee OR $50
membership fee.*
*A Compassion Center membership entitles you to reduced prices in our retail store, free admission to our patient/growers
meetup, reduced prices for our classes, and a waiver of the $25 registration fee.
Steps to complete your registration packet:
1. Complete and sign the new clinic registration form and the medical history form.
2. Complete, date, initial and sign the Authorization for Release of Medical Records form included in this
packet unless you are bringing records in. If you are a new patient, we require one medical record from the
past year and one medical record from more than one year ago documenting your qualifying condition.
We advise our patients to request records from Jan. 1, 2012 to [present date]. Veterans must fill out a VA
Authorization for Release of Medical Records, which can be found at our website.
Please call us if you need assistance in completing any of these forms.
3. Turn your registration packet in to Compassion Center.
4. The medical records staff at Compassion Center will fax or mail the Authorization for Release of Medical
Records form to the doctor or medical facility you have indicated. Once we have received and reviewed
your medical records, we will call to schedule an appointment for the earliest available clinic. It can take 2-4
weeks for your doctor to send records to us.
Please review our Privacy Policy (enclosed with your registration packet and available at our website and office).
FEES FOR ALL PATIENTS:
• $25 registration fee (mentioned above)
• $150 Doctor Appointment and Physical Exam. This fee may be paid before or on the day of your
appointment.
All fees are non-refundable.
Make checks/money orders payable to Compassion Center. We charge $35 for returned checks.
Compassion Center fees are subject to periodic review and change.
We charge $30 for a missed appointment due to no-show or less than 24 hour notice.
NOTE: Registering with Compassion Center as a patient is not the same as registering or renewing with the State of
Oregon for the OMMP. The state requires an application and payment of a fee for registering with the OMMP. For
current information and fees call Oregon Medical Marijuana Program at 971-673-1234.
All Compassion Center records are confidential and secure. Compassion Center will not share these or any records with any individual or organization without the written permission from the patient.
© 2010 Compassion Center Last Updated 01/14 Page 1 2055 W. 12th Avenue. Eugene OR 97402 Phone (541) 484-­‐6558 Fax (541) 484-­‐0891 NEW CLINIC REGISTRATION Last Name ______________________ First _________________ MI ____ DOB ___/___/_____ Phone (___)____-­‐______ Mailing Address ____________________________________ _____ ________________________ _____ ____________ Street Apt# City State Zip Email _______________________________ Emergency Contact: Name __________________ Phone (___)____-­‐______ ☐ I am a Renewal Patient with OMMP and a New Patient with the Compassion Center My qualifying medical condition as I understand it is _______________________________________________ PRESENT MEDICAL CONDITION _______________________________________________ Treatments, surgery, medication, or alternative care prescribed for your condition: _______________________ My condition was diagnosed on or about: ______ ______ ________________________________________________ Month Year My condition was diagnosed by Dr. __________________ At (Clinic/Hospital name) __________________________ ______________________ ____________ ____ ________ Address City State Zip ________________________________________________ Do you plan to use MMJ for another medical condition? ☐ No ☐ Yes If yes, please describe: _________________ _________________________________________________ _________________________________________________ Phone (___) _____-­‐________ How did you hear about the Compassion Center? ☐ Dr. referral ☐Friend/Family ☐ Brochure ☐ Eugene Weekly
☐ Internet ☐ Boomer & Senior News ☐ Cannabis Connection ☐ Other _____________________________________ I would like to establish a relationship with a physician who will work with me and my choices of treatment. I would like to participate in the Compassion Center Clinic Program. The information contained in this application is true and accurate to the best of my knowledge. I also have had an opportunity to review Compassion Center’s Privacy Policy. Patient signature ________________________________________________________________________________________Date Signed______________ ____________________ METHOD OF PAYMENT: VISA MASTERCARD DISCOVER (circle one) My credit card number is __________-­‐__________-­‐__________-­‐__________ Expiration date _____/_______ Amount paid ________________ Signature ________________________________ 3-­‐digit Code # _________ For Staff Use Only Appointment Date _____________ Scheduled by: Initials ___________ COPY ID HERE Date Paid ___________________
Date Paid___________________ Amount $___________________
Amount $__________________ Receipt # ___________________
Receipt # __________________ Initials ___________________
Initials __________________ Cash/Check/Credit Card Cash/Check/Credit Card All Compassion Center records are confidential and secure. Compassion Center will not share these records with any individual or organization without written permission from the patient. © 2010 Compassion Center Last updated 01/13
Page 1 of 2 2055 W. 12th Avenue. Eugene OR 97402 Phone (541) 484-­‐6558 Fax (541) 484-­‐0891 MEDICAL HISTORY Today’s Date ______/_______/_______ Name _______________________________ ______________________________ _____ DOB ______/_______/_______ Last First MI Month Day Year Gender: ☐ Female ☐ Male Relationship status: ☐ Single ☐ Married ☐ Partner ☐ Widowed ☐ Divorced Years of Education: _______ Military: ☐ No ☐ Yes, Veteran for _______ # of years Medical Discharge ☐ Yes ☐ No FAMILY MEDICAL HISTORY FAMILY MEMBERS Do you have any blood relatives who have or have had any of the listed conditions? Please check all that apply. If Living Health Yes No Relationship Cancer __ __ _________________________ Age at time of death Mother Father __ __ _________________________ Sisters and __ __ _________________________ Brothers Epilepsy __ __ _________________________ Diabetes Heart disease HIV/AIDS If Deceased Cause of Age Good Fair Poor Death, if Known __ __ _________________________ Kidney disease __ __ _________________________ Liver disease __ __ _________________________ Children Multiple Sclerosis __ __ _________________________ TB __ __ _________________________ PERSONAL MEDICAL HISTORY Do you have or have you had any of these medical conditions? Please check all that apply. ___ Glaucoma ___ Thyroid Problems ___ Are you pregnant? ___ Emphysema ___ Heart Problems ___ Breast Feeding? ___ TB ___ Blood Pressure Problems ___Other __________________________________ ___ Respiratory disease ___ Stroke Last Chest X-­‐ray _____________________________ ___ Asthma ___ Epilepsy Last Mammogram ___________________________ ___ Cancer ___ Multiple Sclerosis ___ Leukemia ___ Arthritis Surgeries, accidents, injuries, medical conditions, or diseases that required hospitalization in the past five years. ___ Diabetes ___ Rheumatism ___ Stomach Ulcers ___ Migraines ___ Kidney Disease ___ Alzheimer’s Disease ___ Hepatitis or Liver disease ___Nervous Breakdown ___ Congenital Heart Problem ___ Mental/Emotional illness _________________________________Year________ _________________________________Year________ _________________________________Year________ _________________________________Year________ _________________________________Year________ All Compassion Center records are confidential and secure. Compassion Center will not share these records with any individual or organization without written permission from the patient. © 2010 Compassion Center Last updated 01/13
Page 2 of 2 2055 W. 12th Avenue. Eugene OR 97402 Phone (541) 484-­‐6558 Fax (541) 484-­‐0891 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
PATIENT NAME
Date of birth
REQUESTING FROM
/
/
__________________________________________________________________
Name of physician or facility
___________________________________________________________________________
Address
___________________________________________________________________________
Phone
Fax
SEND TO:
Compassion Center
2055 W 12th Ave
Eugene OR 97402
Voice: (541) 484-6558
Fax: (541) 484-0891
*Mail these records if 10 pages or more
*Fax these records if 10 pages or less
I specifically authorize the release of the following records for the purpose of Continuing Care:
From period ___________________to _______________
Date
Date
____X___ Documentation of diagnosis
____X____Radiology Reports
___X___ Physician/clinician chart notes ____X___ Medication List
_______ Other records (please specify): ______________________________
If the information to be disclosed contains the types of records or information listed below, additional laws relating
to the use and disclosure of that information may apply. I understand and agree that this information will be
disclosed if I initial the applicable space next to that type of information.
__HIV/AIDS
__Mental Health
__Drug/Alcohol
__Genetic testing
I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no
longer be protected under the federal law. However, I also understand that federal or state law may restrict redisclosure of
HIV/AIDS information, mental health information, genetic testing information and drug/alcohol diagnosis, treatment, or
referral information.
Refusal to sign this release will not affect 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. To revoke this authorization at time, submit a written request to:
Compassion Center, 2055 W. 12th Avenue, Eugene OR 97402
The only exception is when action has already been taken in reliance on the authorization. Unless revoked earlier,
this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed
to complete the request.
My signature below acknowledges that I understand and accept this release of information.
_____________________________________________________________________________________________
Printed Name
_____________________________________________________________________________________________
Signature
Date
All Compassion Center records are confidential and secure. Compassion Center will not share these records with any individual or organization without written permission from the patient. © 2010 Compassion Center Last updated 01/13
Compassion Center
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.
Summary: Below is a summary of the Notice of Privacy Practices for Compassion Center clinic, volunteers, staff, students, and physicians.
Use and disclosures. We may use health information about you for treatment, to obtain payment for treatment, for administrative purposes and to
evaluate the quality of care that you receive. Continuity of care is part of treatment and we may share your information with other providers to whom
you are referred. We may use or disclose identifiable health information about you without your authorization in several situations, but beyond those
situations we will ask for your written authorization before using or disclosing any identifiable health information about you,.
Your rights. In most cases, you have the right to look at or get a copy of health information about you. If you request copies, we will charge you only
normal photocopy fees. You also have the right to receive a list of certain types of disclosures of your information that we made. If you believe that
information in your record is incorrect, you have the right to request that we correct the existing information.
Our legal duty. We are required by law to protect the privacy of your health information, provide this notice about our information practices, follow the
information practices that are described in this notice and seek your acknowledgement of receipt of this notice. Before we significantly change our
policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. For more
information about our privacy practices, contact the person listed below.
Complaints. If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you
may contact the Executive Director at 541-484-6558, or in writing to 2055 W. 12th Avenue, Eugene OR 97405. You also may send a written complaint to
the US Department of Health and Human services.
Who is subject to this notice. Compassion Center clinic, including its employees, volunteers, and licensed health professionals.
Questions. If you have any questions, please contact our office at 541–484–6558.
Uses and disclosure of your health information.
Following are examples of the types of uses and disclosures of our protected health care information that the provider is permitted to make. These
examples are not meant to be exhaustive, but to describe the types of uses and disclosures.
Treatment: We will use and disclose your health information to give you care and to coordinate and manage your treatment or other services. For
example, if you were previously seen by one doctor at our clinic, and you are seen by another doctor at our clinic, the other doctor may use your health
information created by the previous doctor.
Payment: Your protected health information will be used, when needed, in activities related to obtaining payment for your health care services. For
example, obtaining approval for a hospital stay may require that we disclose your relevant protected health information to your health insurance
company for payment for services
Health care operations: We may use and disclose health information, when needed, in order to support our business activities. For example, when we
review employee performance, we may need to look at what an employee has documented in your medical record.
Appointment reminders, Marketing: We may use and disclose your protected health information to: remind you about appointments with us; tell you
about alternative treatment therapies, providers, or settings of care; and tell you about health-related products, benefits or services related to your
treatment or care. We may send you newsletters about the Oregon Medical Marijuana Act, our services, fundraising, events, wellness programs, general
health matters, changes in the law, and medical uses of marijuana.
Business Associates: We may disclose health information to business associates with which we contract to perform services on our behalf.
Fundraising: We may use limited information about you to raise money for Compassion Center. We may tell you about Compassion Center projects
and services as well as sending you fundraising materials. The fundraising materials will tell you how to opt out of receiving future materials.
Opportunity to Object:
Individuals involved in your care or for notification: We may disclose to a family member, close personal friend, or other person you authorize, certain
health information that is needed for that person’s involvement in your care or payment for your care. Except in limited situations, such as an
emergency, we will ask you or determine whether you object. We may use professional judgment and experience when allowing a person to pick up
health information on your behalf.
Communication Barriers: We may use and disclose your protected health information if we have attempted to obtain acknowledgement from you of
our Notice of Privacy Practices but have been unable to do so due to substantial communication barriers and we determine, using professional
judgment, that you would agree.
Without Opportunity to Object:
We may use or disclose your protected health information in the following situations without your authorization or opportunity to object:
As required by law: We will disclose health information about you when required to do so by federal, state, or local law.
Public health activities: We may disclose your health information for public health activities, including: to a public health authority authorized by law
to collect information to prevent or control disease, injury, or disability; to report actual or suspected child abuse or neglect; and to a person who may
have been exposed to a communicable disease or may be at risk for contracting or spreading a disease or condition, as authorized by law.
Abuse, neglect, or domestic violence: As allowed or required by law, we may disclose health information about an individual we reasonably believe to
be the victim of abuse, neglect, or domestic violence to a government authority authorized to receive such reports.
Health oversight: We may disclose health information to a health oversight agency for activities authorized by law, such as audits, investigations,
inspections, and licensure.
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Lawsuits and disputes: We may disclose health information about you in response to a court or administrative order, subpoena, discovery request, or
other lawful process, as allowed or required by law.
Law enforcement activities: We may disclose health information if required to do so by a law enforcement official only: when required by a law that
mandates certain types of reporting; in response to a court order, subpoena, warrant, summon, certain administrative requests, or similar processes; to
identify or locate a suspect, fugitive, material witness, or missing person (but we will give only limited information); about criminal conduct on our
premises; and, in emergencies, to report a crime, the location of the crime or victims, or the identity, description, or location of the person who
committed the crime.
Research: Under certain circumstances, we may use and disclose health information about you for research purposes. Most of the time, we will ask for
your authorization.
To Avert a Serious Threat to Health or Safety: We may use and disclose your health information when we reasonably believe it is necessary to prevent
a serious threat to the health and safety of you, the public, or another person. The disclosure would only be to someone who is likely to help prevent the threat.
Workers’ Compensation: We may disclose health information about you for workers’ compensation or similar programs.
Incidental Disclosures: Certain incidental disclosures of your health information may occur as a by-product of permitted uses and disclosures. For
example, another patient may inadvertently overhear a discussion about your care.
De-identified Information and Limited Data Sets: We may use and disclose health information that has been “de-identified” by removing certain
identifiers (such as name and address) making it unlikely that you could be identified. We also may disclose limited health information, contained in a
“limited data set,” as allowed by law.
Personal Representatives: We may use and disclose your health information to a “Personal Representative” if you are a minor or an incapacitated adult
when they are designated to act on your and exercise your privacy rights.
Uses and Disclosures with Authorization:
Your authorization: Other uses and disclosures of your health information, including financial information, not covered by this notice or permitted by
law will be made only with your written permission or authorization. You may revoke your authorization, in writing, at any time (unless you are told
otherwise at the time you sign the authorization). If you revoke your authorization, then we will no longer use or disclose your health information for
the reasons covered by your written authorization, except to the extent that we already have relied on your authorization. We are unable to take back
any disclosures we already have made based on your authorization, and we are required to retain our records of the care that we provided to you.
Specially Protected Health Information: Unless otherwise required or permitted by law, we may need your authorization to disclose AIDS/HIV/ARC,
mental health, drug addiction, alcoholism, and other substance abuse treatment, developmental disabilities, and/or genetic information or records.
Your Rights:
Although your health record is our property, you have the rights described below:
Right to Inspect and Copy: We may deny your request in certain limited circumstances. To inspect or obtain a copy of your health information, you
must submit your request on our Request for Release of Medical Records form to the Medical Records Department or the Compassion Center Executive
Director. Compassion Center may charge you a reasonable fee for the costs of copying, mailing, or other supplies related to your request.
Right to Amend: If you believe that health information we have about you is incorrect or incomplete, then you have the right to request a reasonable
amendment for as long as we keep this information. We may deny your request in certain situations. To request an amendment, you must submit your
request in writing to the Medical Records Department or the Compassion Center Executive Director.
Right to an Accounting of Disclosures: You have the right to request an accounting of certain disclosures of your health information made by us. This
accounting will not include disclosures: for treatment, payment, or health care operations; to you under your right of access to your records; that you
authorized; to persons involved in your care or for facility directory and notification purposes; incidental to an otherwise permitted use or disclosure; as
part of a limited data set; or that occurred before April 14, 2003. To request this list or accounting, you must submit your request in writing to the
Compassion Center Executive Director.
Right to Request Restrictions: You have the right to request a limitation on the health information we use about you for treatment, payment, or health
care operations. You also have the right to request a limitation on the health information we disclose about you to someone who is involved in your care
or in payment for your care. You must submit a request for such a limitation in writing to the Compassion Center Executive Director. We are not
required to agree to your request. If we do agree, we will comply with your request unless we need the information to provide emergency treatment.
Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or
at a certain location. To request confidential communications regarding billing or your health information, you must submit your request in writing to
the Compassion Center Executive Director. We will agree to the request if it is reasonable for us to do so.
Right to a Copy of this Notice: You have the right to receive a written copy of this Notice (even if you agreed to receive this Notice electronically).
Copies of the Notice are available from the reception office or the Medical Records Department. You may print a copy of this Notice from our Website at
www.compassioncenter.net.
Our responsibilities:
We are required by law to: maintain the privacy of your health information; give you this Notice of our legal duties and privacy practices with respect to
the information we collect and maintain about you; and follow the terms of the Notice that is currently in effect.
Changes to this notice:
We reserve the right to change this Notice. The revised Notice will be effective for information we already have about you as well as any information we
receive in the future. Unless required by law, the revised Notice will be effective on the new effective date of the Notice. The current Notice will be
available in our registration areas or on our Website and will be posted in our facilities. The Notice will state an effective date.
~~~ End of Notice ~~~
Revised 1/2010
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