Welcome To Clinica! - Clinica Family Health

Transcription

Welcome To Clinica!
A Guide To
Services, Hours
and Important
Information
About Clinica
2013
Page 2
Introduction
Important Phone Numbers
Medical Appointments...................................................303.650.4460
Billing Questions.............................................................720.206.0425
Dental Appointments......................................................303.650.4460
Financial Screening Appointments.................................303.650.4460
Pharmacy Refill Line........................................................720.207.0150
Poison Control Center.....................................................1.800.222.1222
Emergency Assistance.....................................................911
QuitLine .........................................................................1.800.QUIT-NOW
Social Services Assistance...............................................211
Table of Contents
Welcome To Clinica................................................................... Page 3
Locations & Hours of Operation............................................... Page 4
Holidays When We Are Closed................................................. Page 6
My Clinica.................................................................................. Page 7
Services We Offer...................................................................... Page 9
Services We Don’t Offer............................................................ Page 9
Your Rights and Responsibilities............................................... Page 10
Pharmacy Services.................................................................... Page 13
Dental Services.......................................................................... Page 14
Group Visits............................................................................... Page 16
Behavioral Health Services....................................................... Page 16
Referrals To Specialty Care........................................................ Page 17
NextGen Patient Portal............................................................. Page 17
What Is A Medical Emergency?................................................ Page 19
Making An Appointment.......................................................... Page 21
When To Call Us........................................................................ Page 22
Who To Call When We Are Closed............................................ Page 22
Payment Programs at Clinica.................................................... Page 23
Billing Department.................................................................... Page 24
Financial Screening................................................................... Page 25
Financial Screening Hours......................................................... Page 26
Your Comments Count.............................................................. Page 27
Medical Records........................................................................ Page 27
Your Health Records.................................................................. Page 29
Our staff includes family physicians, pediatricians, obstetrician/
gynecologists, dentists, nurse practitioners, physician assistants,
registered dieticians and behavioral health professionals. We have five
medical and two dental clinics where we will care for you when you
are sick, help you stay well and help you manage chronic problems.
Additionally, our administration building has staff who can provide
financial screening and answer questions about your bills.
Here are some things that are important to us:
• We want to provide you with a patient centered medical home. We
do this by building relationships between patients, their primary care
providers and, when appropriate, the patient’s family. We will do
whatever we can to assure that you get the care you need, when you
need it, in a manner that is comfortable for you.
• We believe that your mind affects your body, that what you eat
matters and that preventing disease is better than any prescription.
• Our focus is on keeping you well. We do this by seeing you regularly,
giving you immunizations and offering you health information.
• We want you to see the same team of health care providers at every
visit. You will receive better, more affordable care this way.
• We want you to be involved in your own health care. We will help
you set your own health goals and work towards them.
• We work in teams. Each team member has specific skills so we can
provide most of your care at the clinic. All teams provide the same
services, but each is a different color so you can tell them apart.
Thank you for choosing Clinica as your health care provider.
We look forward to working together to help you and your
family live healthy lives.
Page 3
Since 1977, Clinica Family Health Services has provided health care to
low-income, uninsured people living in southern Boulder, Broomfield
and western Adams counties. We believe that everyone should have
access to basic health care, no matter their ability to pay. We provide
care to young and old, men and women, people with jobs and those
without.
Introduction
Welcome to Clinica!
Page 4
Introduction
Our Locations & Hours
Financial Screening
1345 Plaza Court North, 1A
Lafayette, CO 80026
Administration Building
Monday
Opens 8am
Lunch 1-2pm
Closes
5pm
Tuesday
8am
1-2pm
5pm
Wednesday
8am
1-2pm
5pm
Thursday
8am
1-2pm
5pm
Friday
8am
1-2pm
5pm
8300 N. Alcott, #205
Westminster, CO 80031
Federal Heights Medical Clinic
Monday
Opens 8am
Lunch 1-2pm
Closes
5pm
Tuesday
8am
1-2pm
8pm
Wednesday
8am
none
1pm
Thursday
8am
1-2pm
5pm
Friday
8am
1-2pm
5pm
Pharmacy Outlet
2000 W. South Boulder Rd.
Lafayette, CO 80026
Lafayette Medical Clinic
Monday
Opens 8:45am Lunch 1-2pm
Closes
5:30pm
Tuesday
8:45am
1-2pm
6:30pm
Wednesday
8:45am
1-2pm
5:30pm
Thursday
8:45am
1-2pm
6:30pm
Friday
7:45am
1-2pm
4:30pm
Introduction
Pharmacy & Financial Screening
1701 W. 72nd Ave.
Denver, CO 80221
Monday
Opens 8am
Lunch 1-2pm
Closes
6pm
Tuesday
8am
1-2pm
8pm
Wednesday
8am
1-2pm
8pm
Thursday
8am
1-2pm
8pm
Friday
7:45am
1-2pm
5pm
Pharmacy & Financial Screening
2525 13th Ave.
Boulder, CO 80304
People’s Medical Clinic
Monday
Opens 8am
Lunch 1-2pm
Closes
5pm
Tuesday
8am
1-2pm
8pm
Wednesday
8am
1-2pm
5pm
Thursday
8am
1-2pm
8pm
Friday
8am
1-2pm
5pm
Pharmacy Outlet
8990 N. Washington St.
Thornton, CO 80229
Thornton Medical & Dental Clinic
Monday
Opens 8am
Lunch 1-2pm
Closes
5pm
Tuesday
8am
1-2pm
8pm
Wednesday
8am
1-2pm
8pm
Thursday
8am
1-2pm
8pm
Friday
8am
1-2pm
5pm
Page 5
Pecos Medical & Dental Clinic
Page 6
For Call Center hours
Introduction
see page 22
For Financial Screening hours
see page 26
For Pharmacy hours
see page 13
Holidays When We Are Closed
• New Year’s Day (January 1)
• Martin Luther King, Jr., Day (third Monday of January)
• Memorial Day (last Monday of May)
• Independence Day (July 4)
• Labor Day (first Monday of September)
• Thanksgiving Day (fourth Thursday of November)
• Day After Thanksgiving (fourth Friday of November)
• Christmas Break (December 24 and December 25)
FAMILY MEMBERS
My Spouse’s PCP: ________________________________________
His/Her Care Team’s Color: ________________________________
His/Her Primary Dental Provider: ___________________________
His/Her Clinic: __________________________________________
Child #1’s PCP: __________________________________________
His/Her Clinic: __________________________________________
Child #2’s PCP: __________________________________________
His/Her Clinic: __________________________________________
Child #3’s PCP: __________________________________________
His/Her Clinic: __________________________________________
Child #4’s PCP: __________________________________________
His/Her Clinic: __________________________________________
Page 7
My Primary Care Provider (PCP): ____________________________
My Care Team’s Color: ____________________________________
My Primary Dental Provider: _______________________________
My Clinic: ______________________________________________
Introduction
My Clinica
Page 8
About Clinica
Services, Patient Rights & Responsibilities
About Clinica
•
•
•
•
•
•
•
•
•
Well visits ̶ Regular check-ups, sports or school physicals
Acute care ̶ Care for an illness such as fever or sore throat
Preventive care ̶ Screenings to help you stay well
Obstetric and gynecological care ̶ Prenatal and women’s care
Minor surgical procedures ̶ Procedures not requiring anesthesia
Cancer screenings ̶ Tests looking for cancer
Health education ̶ Learning to take care of yourself
Nutrition counseling ̶ Learning how to eat healthily
Behavioral health care for individuals or families ̶ Help when you
are depressed, anxious or have emotional problems
• Citizenship and Immigration Services (CIS) physicals ̶ Check-ups
when applying for U.S. citizenship
• Immunizations ̶ Shots to keep children and adults healthy
• Dental care ̶ Care of your teeth
• Pharmacy services ̶ Filling prescriptions from your provider
• Outreach services ̶ Contacting you by phone or mail when you are
due for an appointment.
The medical and dental care that your provider gives you is based on the
most current and proven practices currently used in medicine. Please
ask us if you have any questions about your treatment plan.
Services We Do Not Offer
•
•
•
•
•
Medical X-rays or other imaging services (we do offer dental X-rays)
Specialty care (please see page 17)
Walk-in services
Emergency care (please see page 19)
Department of Transportation physicals
Page 9
Services We Offer
About Clinica
Clinica has five locations. We try to assign you to the clinic that
is closest to where you live. Once you choose your health care
provider, we want you to see that provider whenever possible. Your
provider is part of a team of health care professionals, all working
together to provide you the best care possible. We believe that you
receive better health care if you see the same person ̶ or same team
of people ̶ at each visit. When you schedule an appointment, we will
try to make sure that you see your provider or a member of your
provider’s team.
About Clinica
Page 10
Your Rights As Our Patient
• ACCESS. Appointments are provided within a reasonable period of
time and charges will be affordable based on your family size and
income. You will be treated without discrimination as to race, color,
gender, national origin, political beliefs or handicaps.
• DIGNITY. Care is provided in a manner that respects your
individuality and dignity.
• PRIVACY. All physical exams, interviews and discussions about your
health will occur privately and your medical records will be handled
confidentially.
• EMPLOYEE IDENTIFICATION. You have the right to know the names,
professional status and experience of the staff who are providing
your care.
• CONSENT. Consent for treatment will be requested by our medical
staff before any procedure is performed. The procedure and its
value, risks and other options for treatment will be explained.
• REFUSAL OF TREATMENT. You have the right to refuse any care
recommended.
• ACCESS TO RECORDS. You may review or receive a copy of your
medical record within 10 days of your written request for records.
• RESEARCH. You will be provided with information and an
opportunity to consent before any experimental treatment and/or
test.
• BILLS. You have a right to an explanation of all charges and slidingfee scale adjustments.
Your Responsibilities As Our Patient
• INFORM. Please give full and honest information. This includes
complete medical records or a complete medical history, information
on any medications you take and any other providers that you see
outside Clinica Family Health Services.
• FOLLOW INSTRUCTIONS. Follow your health care provider’s
instructions. If you have any questions, please ask.
• BE ON TIME. Arrive for your appointment on time. If you need to
miss an appointment, please call 24 hours in advance.
• REPORT EMERGENCIES. Call the emergency phone numbers
provided to you if you suffer an emergency and notify your health
care provider of any emergency within 24 hours.
• SHOW INSURANCE CARD. Show your insurance card (including your
Medicaid ID card) at each visit.
• FINANCIAL SCREENING. Complete the financial screening process
by bringing all insurance, income and other required information to
the clinic within 30 days of your first visit.
• PAY BILLS. Your fees will be adjusted so that they are affordable for
you. Please pay your co-payments and bills promptly.
Page 11
• REPORT CHANGES. Report any changes in your condition,
symptoms and allergies.
About Clinica
• FOLLOW CLINIC RULES. Follow rules including the consideration of
the rights of other patients and staff. Please assist with the control
of noise and observe the no-smoking policy.
Page 12
Health Care Services
Pharmacy, Dental, Groups, Behavioral Health, Specialists, NextGen, Emergencies
Other Health Services
Clinica has two full-service pharmacies with a pharmacist on staff to
fill prescriptions while you wait. These are located at our People’s and
Pecos facilities. The Lafayette and Thornton clinics have pharmacy
outlets. Outlets have a limited stock of medications and cannot usually
refill prescriptions while you wait.
While we stock many common medications, some prescriptions might
need to be filled at a commercial pharmacy. For prescription refills,
please call 720.207.0150.
Please allow 48-72 hours for your prescription to be filled if you call
the refill line. This is especially true if you are picking up prescriptions
at one of our pharmacy outlets.
Monday
Opens 8:30am
Lunch 1-2pm
Closes
5:30pm
Tuesday
8:30am
1-2pm
7:30pm
Wednesday
8:30am
1-2pm
7:30pm
Thursday
8:30am
1-2pm
7:30pm
Friday
8:30am
1-2pm
4:30pm
People’s Pharmacy
Monday - Friday
Opens 8:30am
Lunch 1-2pm
Closes
4:30pm
Lafayette Pharmacy Outlet
Monday
Opens 9:30am
Lunch 1-2pm
Closes
5:30pm
Tuesday
9:30am
1-2pm
5:30pm
Wednesday
9:30am
1-2pm
5:30pm
Thursday
9:30am
1-2pm
5:30pm
Friday
8:30am
1-2pm
4:30pm
Thornton Pharmacy Outlet
Monday - Friday
Opens 8:30am
Lunch 1-2pm
Closes
4:30pm
Page 13
Pecos Pharmacy
s
Pharmacy Services
Page 14
Dental Services
We have two dental clinics. Patients who see medical providers at the
Pecos, Federal Heights or People’s clinics receive dental care at the
Pecos Dental Clinic, located on the first floor of the Pecos Medical and
Dental Clinic.
Patients who see medical providers at either the Lafayette or Thornton
clinics receive dental care at the Thornton Dental Clinic, located in the
Thornton Medical Clinic.
For dental appointments, call 303.650.4460.
Dental Clinics
Monday - Friday
Opens 8am
Lunch 1-2pm
Closes
5pm
WHO IS ELIGIBLE FOR CLINICA DENTAL CARE?
Any patient with an established medical provider and a discount rating
at Clinica is eligible for care in the Dental Clinics. New patient group
visits do not count as having an established provider.
New patients are welcome to our dental clinics! However, first priority
for appointments is given to children under 18 years old, pregnant
women and diabetic patients. We currently are accepting new pediatric
patients at both dental clinics. Please call 303.650.4460 to make an
appointment.
For all others,
appointments are
given on a first-come,
first-served basis,
and there is often a
waiting list to be seen.
On most days, we
have a few limited
care appointments
available for patients
who have an urgent
problem (severe
pain, infection or
swelling), which are
COST OF CLINICA DENTAL SERVICES
Payment for dental treatment is due at or before the time of service, and the
cost will vary depending on your insurance coverage or discount.
The dental clinics accept Medicaid, CHP+ and the Clinica discount rating.
Patients with other forms of dental insurance are encouraged to find dental
care outside of Clinica.
Patients with a Clinica discount will pay a portion of the total cost of their
treatment, which will differ at each appointment, depending on the services
they receive. You will be quoted prices on the services to be provided before
each appointment. For more information, please contact one of our dental
clinics.
Page 15
CLINICA DENTAL
SERVICES
We provide both general and specialty services for children and general
dentistry for adults.
• For patients of all ages: exams, fillings, cleanings, some extractions and root
canals.
• For children under 12 years old: crowns, nitrous sedation and hospital
services.
• All other specialty services (crowns, bridges, implants, dentures or partials,
cosmetic dentistry, complex extractions and complex root canals) are
referred to dental providers outside of Clinica.
• You may meet one of our dental hygienists during a routine medical visit.
Hygienists sometimes join group visits (see page 16) or meet with pregnant
women, parents or children during one-on-one medical visits to provide
important information on keeping smiles healthy, preventive dental
treatments or assistance with obtaining dental services.
also available on a
first-come, first-served
basis. Please note
that the goal of these
appointments is to
address one urgent
issue only, not provide
full treatment of the
mouth.
Page 16
Group Visits
In addition to traditional one-on-one appointments, Clinica offers
patient care through group visits. A group visit is when 6-8 patients with
the same health need are seen at the same time. Instead of meeting in
an exam room, group visits are held in larger, more comfortable spaces.
In addition to your clinician, members of your clinician’s team join the
groups. You receive all the care you would in an exam room, but you
also get to hear from behavioral health professionals, nutritionists,
dental hygienists or pharmacists. Groups are very interactive and last
much longer than traditional appointments. You have time to ask
questions, share
past experiences
and learn from
other patients in
the group.
Participating
in groups is
voluntary, but
many patients find
group visits much
more enjoyable
than one-on-one
care.
Behavioral Health Services
Your physical, mental and emotional health are linked. Keeping you
healthy means that we want to help you take care of both your body
and your mind. Every health care team has a behavioral health provider
with specialized training to help you when you are depressed, anxious
or experiencing other emotional problems. They can also help you quit
smoking or work on family problems. These types of support from our
staff are tailored to each patient’s individual needs. These behavioral
health provides works side-by-side with your primary care provider.
They can provide short-term counseling and support in our clinics
for behavior changes. Each of our healthcare teams also has a case
manager who will work with you to set goals for improving your health
and can link you with resources in the community that might help you.
Referrals to Specialty Care
If you do see a specialist outside of Clinica, you are responsible for the
bill. Please make time to work with the staff in the specialist’s office on a
payment plan.
NextGen Patient Portal
PATIENT PORTAL USES
• Routine medical questions and requests: send us an e-mail any time
of the day.
• Request appointments on-line: enter the days and times you wish
to come for a visit and we will e-mail you back with an appointment
time.
• Medication refills: request medication refills for pick up at one of our
pharmacies or an external pharmacy.
• Lab results: we will be able to send you certain lab results and other
important personal health information.
• Search for patient health education information: the web site has
options for accessing generic health information.
IMPORTANT POINTS ABOUT USING THE PATIENT PORTAL
• E-mails should never be used for urgent or life-threatening medical
problems.
• You can expect an e-mail
response from us within
2-3 business days.
• Patient Portal
communication will
Page 17
Patients can securely e-mail their clinica providers using a computer
program called the NextGen Patient Portal. This is a free service that we
provide to all of our patients.
Occasionally you may need care or services that we do not provide at
Clinica. In these situations we will refer you to an outside specialist for
care. However, the availability of specialty care is very limited and, at
times, may not be available to uninsured or underinsured patients.
•
Page 18
•
•
•
•
become a permanent part of your medical record.
The reply to your e-mail may be from any member of your provider’s
team.
If you sign up for the Patient Portal, please agree to check your
e-mail several times a week since we will use this web site to
communicate with you about your health care.
You will need an enrollment token (it expires 30 days after you
receive it) to complete enrollment at home.
You can communicate on behalf of other family members via the
Patient Portal.
Inappropriate use of the Patient Portal may result in us terminating
your access to the web portal.
If you have any questions about using the NextGen Patient Portal, please
call the Call Center or go to our web site at www.clinica.org and look
under the “Patient Services” tab for detailed instructions.
Unfortunately we cannot help you with any internet connection issues
or personal computer issues you may have. Although the web site is
only available in English, we are happy to e-mail you in Spanish.
What is a Medical Emergency?
FOLLOW-UP CARE
You are responsible for calling the clinic for follow-up care after going to
an urgent care facility, being seen in a hospital emergency department
or being admitted to a hospital.
HOSPITALS WHERE WE SEE PATIENTS
Clinica providers see hospitalized patients at Avista Adventist Hospital
in Louisville. Clinica providers also work closely with staff at St. Anthony
North Hospital in Westminster to care for Clinica patients. Hospital
care is separate from what you receive at Clinica. If you are seen at a
hospital, you are responsible for the bill. Please make time to work with
the hospital on a payment plan.
Avista Adventist Hospital
100 Health Park Drive
Louisville, CO 80027
303.673.1000
St. Anthony North Hospital
2551 W. 84th Avenue
Westminster, CO 80031
303.426.2151
Page 19
WHAT IS AN URGENT NEED?
An urgent care need is one that requires prompt medical attention
(usually within 24 to 48 hours) but is not an emergency condition.
Examples of urgent care situations include: minor injuries, sore throats,
upper respiratory symptoms, earaches, coughs, backaches, frequent
urination or burning when urinating. If you have urgent symptoms,
please call 303.650.4460 whether during normal business hours or after
hours.
An emergency condition is a medical or mental health problem that
is severe and could cause permanent bodily damage or death. If
you think you are experiencing an emergency, go to the nearest
emergency room or call 911 immediately! If you are not sure what
type of care you need, please see below for who to call.
Page 20
Patient Services
Appointments, Payments, Financial Screening, Feedback, Medical Records
Patient Services
Making An Appointment
• Please call 303.650.4460 to make or cancel any appointment.
• We are not a walk-in or urgent care clinic. Please do not expect to
see a provider unless you have an appointment.
• Our Call Center schedules visits for all of our clinics.
• In order to see all of our patients and stay on time, we must
limit appointment times. We may not be able to meet all your
needs in one visit, so you may have to come back for a follow-up
appointment.
• Please call the Call Center if you need to cancel an appointment. If
the Call Center is closed, please leave a message on the cancellation
message line. Excessively or repeatedly missing appointments
without canceling may lead to us terminating your care at all Clinica
locations.
• Family members
are allowed to
make, confirm,
reschedule
and cancel
appointments
for other family
members. Please
let us know if you
wowuld like to
place limitations
on your account.
Page 21
• We offer sameday appointments
in many cases and
will try to find you
an appointment
time within 48
hours of when
you call us.
Patient Services
• Come to your visit on time. If you are more than 15 minutes late for
your appointment, you may need to reschedule your visit.
When To Call Us
Clinica has a Call Center with staff who are specially trained to answer
your questions, make or cancel appointments for each site or put you
in touch with a nurse if necessary. The Call Center is open:
Page 22
Call Center
Monday
Opens 8am
Lunch 1-2:20pm
Closes
5pm
Tuesday
8am
1-2:20pm
5pm
Wednesday
8am
1-2:20pm
5pm
Thursday
8am
1-2:20pm
5pm
Friday
8am
1-2:20pm
4pm
Patient Services
PLEASE CALL US FOR:
• Scheduling or cancelling an appointment
• Medication refills (might take up to 72 hours)
• Questions about medications
• Concerns, complaints or compliments
• Leaving a message for someone on your provider’s team
• Lab results
• Cancelling appointments even when the clinic is closed
WHO TO CALL WHEN WE ARE CLOSED
If you have an urgent problem that requires immediate attention
during non-business hours, please call 303.650.4460 for
directions on how to speak with the person on call.
303.650.4460
Payment Programs at Clinica
Clinica is a Federally Qualified Health Center (FQHC). We receive
funding from federal, state, county and city agencies that helps us serve
patients who are uninsured, underinsured or have Medicare, Medicaid
or CHP+. All Clinica patients must complete an annual financial
screening process to determine which of our payment programs is best
for you and your family.
• Must be a Colorado resident or migrant farm worker and a U.S.
citizen or legal immigrant.
• Must have combined income and resources at or below 250% of the
federal poverty level.
• Cannot be eligible for Medicaid or Child Health Plan Plus (CHP+).
CICP is NOT a health insurance program and is limited in where it can be
used and what it covers.
CLINICA SLIDING-FEE SCALE
Clinica’s sliding-fee scale is based on your family size and income. It is
used for patients who do not qualify for CICP and have incomes at or
below 200% of the federal poverty level. You do not have to prove that
you are a Colorado resident to qualify for our sliding-fee scale.
Page 23
CICP
The Colorado Indigent Care Program (CICP) provides funding to clinics
and hospitals so that medical services can be offered at a discount to
Colorado residents. Patients must meet the eligibility requirements
established by the State of Colorado. All applicants must go through an
application process yearly and must meet the following requirements to
participate in CICP:
Patient Services
MEDICAID AND CHP+
Family Medicaid and CHP+ are public health insurance programs
for families, children and pregnant women that are provided by the
State of Colorado. When you apply, you are applying for both Family
Medicaid and CHP+. The program you qualify for depends upon your
family’s size, income and the age of the applicant. Clinica can assist you
in completing these applications at our sites and send the applications
to the appropriate agencies for processing.
Patient Services
Page 24
PRIVATE INSURANCE
If you get insurance after you become a Clinica patient, through an
employer or through a health exchange, you will most likely be able to
continue your care at Clinica. We accept most types of private insurance.
We will bill your private insurance for all charges. If you have a high
deductible or co-payment, you may use your sliding scale to cover part
or all of your co-payment amount.
SELF-PAY
If your income is above 250% of the federal poverty level and do not
qualify for any of the above plans, you would be considered a “self-pay”
patient. You would be responsible for payment of all medical and lab
services at the full fee.
IMPORTANT NOTE
Your Clinica discount is not health insurance. The discount you have
for health care at Clinica might not be accepted at health care facilities
outside of Clinica. Always check on costs and payment policies when
receiving health care services outside of Clinica. If you receive care at an
area hospital or specialist’s office, Clinica is not responsible for paying
those expenses.
Billing Department
To reach the Billing Department, please call 720.206.0425.
Billing Department
Monday - Friday
Opens 7:30am
Lunch 1-2pm
Closes
4:30pm
BILLING STATEMENTS
Patients with an outstanding balance receive a statement every 28
days. Statements only go to patients with a balance of $10 or more.
MAKING PAYMENTS
Patients can make payments with a credit or debit card on-line at www.
clinica.org or by calling 720.206.0425.
PAYMENT PLANS
We offer payment plans without any penalty. If you would like to set up
a payment plan, please call us at 720.206.0425.
Financial Screening
Financial screening is a process of determining which payment program
you and your family qualify for or how much you should pay on Clinica’s
sliding-fee scale. Because your financial situation can change, we
require patients to update their financial screening every year. Please
make financial screening appointments by calling the Call Center.
Following is a list of documents that you might need to bring to your
financial screening appointment.

Bring all necessary documents to your appointment. You will not be
financially screened if you arrive without the necessary documents.
If you cannot bring one or more of the documents, please cancel your
appointment and reschedule once you have all thee documentation.
My type of discount: ________________________________________
Date when my discount expires: _______________________________
Page 25

Picture ID for all adult applicants
Car registration
Social Security numbers for entire family
Legal Permanent Resident Card if resident of US
Proof of address under patient’s name: utility bill, water bill for
either the previous or current month
Insurance, Medicaid and/or Medicare cards
Proof of unearned income: child support, SSI, DSSI, unemployment
If self-employed, bring last month’s business ledger
If pregnant, bring proof of pregnancy, Social Security card and
picture ID or birth certificate
Passports, birth certificates, Colorado IDs or school IDs for all
children under 18
All check stubs from previous month or signed and dated letter
from employer stating hours worked per week, pay per hour, if you
are paid weekly or bi-weekly and gross income from the last month
If living with someone else, bring signed and dated letter from that
person. Letter should include address, phone number and when
you moved in. Also bring a utility bill for previous or current month
from that person.
Patient Services

Financial Screening Hours
Patient Services
Page 26
At Administration
Monday
Opens 8am
Lunch 12:40-2pm
Closes
5pm
Tuesday
8am
1-2pm
5pm
Wednesday
8am
1-2pm
5pm
Thursday
8am
1-2pm
5pm
Friday
8am
1-2pm
4:30pm
At Pecos
Monday
Opens 8am
Lunch 1-2:20pm
Closes
5pm
Tuesday
8am
1-2pm
7:30pm
Wednesday
8am
1-2:20pm
7:30pm
Thursday
8am
1-2pm
7:30pm
Friday
8am
1-2pm
4:30pm
Monday
Opens 8am
Lunch 1-2pm
Tuesday
8am
1-2pm
5pm
Wednesday
8am
1-2pm
5pm
Thursday
8am
12:45-2pm
5pm
Friday
8am
1-2pm
4:30pm
At People’s*
Closes
5pm
* Hours vary. Please check with the Call Center when making an appointment.
Clinica is very interested in your feedback on how we can improve your
experience as a patient. If something went well or did not go well, we
want to know so we can improve our customer service. We have cards
at each Clinica site to collect your impressions. These are called “Your
Comments Count” cards.
If you ever want to share suggestions or comments (good or bad),
ask any Clinica employee for a “Your Comments Count” card. Fill out
the information and drop it off at the clinic or mail it in, whichever is
more convenient for you. You can also contact the Call Center and an
attendant or a manager can take your information. “Your Comments
Count” cards are available at all
of our medical and dental clinics
and at the administration office.
Medical Records
You have the right to request a copy of all or a portion of your
medical records at any time. We are only allowed to release your
Clinica records to you. If you are interested in obtaining a copy of
your medical records, you will need to complete an Authorization For
Release Of Medical Information form. You may obtain one of these
forms at your clinic. Please know that processing these requests may
take 3-5 business days, and there may be a charge associated with
obtaining your records.
Page 27
All “Your Comments Count”
cards are reviewed by a
manager. You will receive a call
from a clinic manger regarding
your comment or suggestion
so that you know we received
your feedback. Remember,
you are the best person to
tell us how we can better
serve you.
Patient Services
.
Your Comments Count
Page 28
Health Information
Health Information, BMI Scale, Blood Pressure Table, Health Goals
Your Health Records
Blood Sugar
LDL (bad
cholesterol)
HDL (good
cholesterol)
Total
Cholesterol
Pulse
Blood
Pressure
Date
Weight
My Health Information
Health Information
Page 29
MY NEXT DENTAL APPOINTMENT IS:
Date:
_______ _______ _______
Time:
_______ _______ _______
_______
_______
_______
_______
_______
_______
Body Mass Index (BMI)
BMI
19
20
21
22
23
24
25
Page 30
Height
26
28
29
30
31
32
33
34
35
4’10”
91
96
100
105
110
115
119
124
129
134
138
143
148
153
158
162
167
4’11”
94
99
104
109
114
119
124
128
133
138
143
148
153
158
163
168
173
5’
97
102
107
112
118
123
128
133
138
143
148
153
158
163
168
174
179
5’1”
100
106
111
116
122
127
132
137
143
148
153
158
164
169
174
180
185
5’2”
104
109
115
120
126
131
136
142
147
153
158
164
169
175
180
186
191
5’3”
107
113
118
124
130
135
141
146
152
158
163
169
175
180
186
191
197
5’4”
110
116
122
128
134
140
145
151
157
163
169
174
180
186
192
197
204
5’5”
114
120
126
132
138
144
150
156
162
168
174
180
186
192
198
204
210
5’6”
118
124
130
136
142
148
155
161
167
173
179
186
192
198
204
210
216
5’7”
121
127
134
140
146
153
159
166
172
178
185
191
198
204
211
217
223
5’8”
125
131
138
144
151
158
164
171
177
184
190
197
203
210
216
223
230
5’9”
128
135
142
149
155
162
169
176
182
189
196
203
209
216
223
230
236
5’10”
132
139
146
153
160
167
174
181
188
195
202
209
216
222
229
236
243
5’11”
136
143
150
157
165
172
179
186
193
200
208
215
222
229
236
243
250
6’
140
147
154
162
169
177
184
191
199
206
213
221
228
235
242
250
258
6’1”
144
151
159
166
174
182
189
197
204
212
219
227
235
242
250
257
265
6’2”
143
155
163
171
179
186
194
202
210
218
225
233
241
249
256
264
272
6’3”
152
160
168
176
184
192
200
208
216
224
232
240
248
256
264
272
279
Healthy weight
Health Information
27
Weight in pounds
Overweight
Blood Pressure
Top number
(systolic)
Below 120
120-139
Bottom
number
(diastolic)
and Below 80
or
80-89
Obese
Your category
What to do
Normal blood
Maintain or adopt a healthy
pressure
lifestyle.
Prehypertension
Maintain or adopt a healthy
lifestyle.
140-159
or
90-99
Stage 1 hypertension Maintain or adopt a healthy
lifestyle. If blood pressure goal
isn’t reached in about six months,
talk to your doctor about taking
one or more medications.
160 or more
or
100 or more
Stage 2 hypertension Maintain or adopt a healthy
lifestyle. Talk to your doctor about
taking more than one medication.
* Ranges may be lower for children and teenagers. Talk to your child’s doctor if you’re
concerned your child has high blood pressure.
My Health Goals
My nutrition goal: ____________________________________________
___________________________________________________________
My fitness goal: _____________________________________________
___________________________________________________________
My behavioral health goal: _____________________________________
Health Information
___________________________________________________________
Page 31
Clinica is recognized
by the National
Committee for Quality
Assurance as a Level
III Patient Centered
Medical Home.
OP-167.1-01/13-PR