Assurance Healthcare & Counseling Center

Membership Family Medicine in Yakima, WA

Disclosures

Welcome to Assurance Healthcare & Counseling Center!

First, a little disclosure regarding this website…

This website assurancehealth.org (“Site”) is operated by Assurance Healthcare & Counseling Center, LLC., a Washington limited liability corporation doing business as Assurance Healthcare & Counseling Center in Yakima, WA. Throughout the Site the words “we”, “us” and “our” refer to Assurance Healthcare & Counseling Center, LLC, also known as “Assurance Healthcare & Counseling Center,” “Assurance,” “Assurance Health,” or “AHCC.”

Now, we get into the details of our disclosures when you become a member of Assurance Healthcare & Counseling Center…

PLEASE READ THESE TERMS CAREFULLY! By becoming a member or accepting or using our product / service, you acknowledge that you agree to these terms in their entirety.

Terms

  • I acknowledge and understand that I am voluntarily becoming an Assurance Healthcare & Counseling Center (AHCC) patient and that this agreement is non-transferable.
  • I acknowledge and understand that this agreement does not provide comprehensive health insurance coverage nor is it a contract of insurance and that it provides only the health care services specifically described in the AHCC Patient Services Guide.
  • I have reviewed the AHCC Patient Services Guide and I have had the opportunity to ask questions and receive answers regarding its content.
  • I acknowledge and understand that I am responsible for any charges incurred for health care services performed outside of AHCC including but not limited to emergency room, hospital and specialty services and that AHCC will not bill insurance carriers for any services provided by AHCC.
  • I acknowledge and understand that AHCC must maintain a record my health information and must protect the privacy of my health information as per the terms of the Notice of Privacy Practices. I understand and acknowledge that this policy is available for my review at any time at https://assurancehealth.org/privacy-policy or upon request.
  • I acknowledge and understand that I may terminate this Patient Agreement at any time and for any or for no reason by providing written notice to AHCC via our Membership Cancellation Form, which is available via our website at https://assurancehealth.org/forms. Monthly fees will continue to accrue until the Membership Cancellation Form is received. Should membership be terminated prior to the initial six (6) month contract period (see below), an early termination fee may apply. Any pre-paid monthly care fees will be prorated to the date AHCC has received my written termination and refunded to me within ten (10) business days. AHCC will not terminate this Patient Agreement solely on the basis of health status.
  • I acknowledge and agree to pay my monthly care fee on or before its due date. In the event that I am unable to pay my fee(s) on time, I understand that I will be charged a $25 late fee and that my membership agreement may be terminated.
  • In addition, I acknowledge and understand that Assurance may add or discontinue services or may increase my fee schedule at any time (but no more than once per year), and that I will be given, in writing, at least sixty (60) days notice of such fee schedule changes.
  • I acknowledge and understand that if I am enrolled in Medicare I will receive a copy of the Medicare Opt-out Agreement for review and signature prior to my first appointment. (The Opt-out Agreement does not prevent me from receiving current or future Medicare benefits from non-AHCC providers; neither I nor my AHCC health care provider(s) will seek reimbursement from Medicare for the medical services I receive from AHCC)
  • I understand there is a six (6) month minimum membership requirement. If I decide to terminate my membership within the first six (6) months of membership, early termination fees may apply.

Rights & Responsibilities

  • I understand that I have the right to receive accurate and easily understood information about AHCC’s healthcare services, healthcare professionals and healthcare facilities. If I speak a language different from my clinician, have a physical or mental disability or do not understand something, I understand that AHCC will make their best effort to provide assistance so I can make informed healthcare decisions. I am responsible for providing my own translator if necessary.
  • In the event of membership termination, I understand that I must complete a written Membership Cancellation Form. Any differences in payment between my billing date and the date of cancellation will be refunded to me via the payment method I have chosen for my monthly membership fee. I understand that if my account is overdue, I am responsible for resolving the outstanding balance prior to my membership cancellation, including any early termination fees. If an outstanding balance remains after membership cancellation, AHCC reserves the right to make due any previous outstanding balances before restarting membership.
  • I understand that I have the right to considerate, respectful, and nondiscriminatory care from my AHCC clinician(s). I also understand that I am responsible for communicating clearly and respectfully with my clinician. Should I become dissatisfied with my care or AHCC’s services, I agree to notify AHCC immediately so my concerns may be addressed in a timely manner.
  • I understand that I have the right to know all of my treatment options and to participate in my healthcare decisions. Parents, guardians, family members or other individuals whom I designate may represent me if I cannot make my own decisions.
  • I understand that I have the right to speak in confidence with my AHCC provider(s) and to have my healthcare information protected. I understand that AHCC will not disclose my information without my authorization or without a legal obligation to do so.
  • I understand that I have the right to a fair, fast and objective review of any complaint I have against my healthcare clinician(s) or any other staff. I agree to first bring any complaints to the attention of AHCC staff and to participate in the AHCC complaint and grievance process.
  • In order to receive the best possible care, I agree to be actively involved in my healthcare decisions and to disclose all relevant information to my AHCC healthcare clinicians(s) so they can help me achieve my health goals. I also agree to inform my AHCC health care clinician(s) of any healthcare services I receive outside of AHCC (such as emergency room, specialist, or hospital services).

Acknowledgement of Privacy Practices (HIPAA)

We want to inform you of the rights you have as a patient under the Health Insurance Portability & Accountability Act of 1996 (HIPAA).

Under HIPAA, I understand that my personal information may be used to:

  • Provide and coordinate my treatment among a number of healthcare providers who may be involved in my treatment directly or indirectly.
  • Obtain payment from third-party payers for my healthcare services.
  • Conduct normal healthcare operations such as quality assessment and improvement activities.

I have been informed of Assurance Healthcare & Counseling Center’s (AHCC) Notice of Privacy Practices and understand that I may request a copy of this Notice for my own use. I understand that Assurance Healthcare & Counseling Center has the right to change the Notice of Privacy Practices and that I may contact this office to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I further understand that AHCC is not required to accept my requested restrictions, but if they are accepted than I understand that AHCC will honor my request unless it is an emergency.

I further understand that I have the right to not sign this acknowledgment in order to receive treatment at AHCC.

Upon signing the member registration form, I acknowledge and understand that this information will be kept in my medical record and the instructions given in my member registration form regarding the authorization to community Protected Health Information will be honored until revoked by me in writing. It is my responsibility to notify AHCC should I change one or more of the authorized individuals or telephone numbers listed on my registration.

Authorization to Email Protected Health Information and Alert for Electronic Communication

Although secure electronic messaging is preferred, unsecure email communication containing sensitive health information can be sent between an Assurance Healthcare & Counseling Center (AHCC) provider and patient.

Patients and/or personal representatives who want to communicate with their health care providers by email should consider all of the following issues before signing an Authorization to Email Protected Health Information:

  1. Email at AHCC can be forwarded, intercepted, printed and stored by others.
  2. Email Communication is a convenience and is not appropriate for emergencies or time sensitive issues.
  3. Highly sensitive or personal information should only be communicated by email at the patient’s discretion (i.e. HIV status, mental illness, chemical dependency, etc.)
  4. Employers generally have the right to access any email received or sent by a person at work.
  5. Staff other than the health care provider may read and process email.
  6. Clinically relevant messages and responses will be documented in the medical record at the provider’s discretion.
  7. AHCC will not be liable for information lost or misdirected due to technical errors or failures.
    I have read and understand the Alert for Electronic Communications and agree that email messages may include protected health information about me/the patient, whenever necessary.

If the registration form section labeled, “Can AHCC email you regarding your health information?” indicates a “yes,” then unsecure email communication regarding the patient’s medical care and treatment may be used to transmit information between the patient and AHCC.

I understand that any email transmission between my provider and me/the patient/member may become part of my medical record (which AHCC privacy policies still remain in affect). These email transmissions may be disclosed in accordance with future authorizations.

I understand that I have the right to revoke this Authorization at any time by indicating so in writing. I understand that if I revoke this Authorization, it will not apply to any information already released as a result of this authorization.

I understand that this Authorization is voluntary and that I may refuse to sign it. I also understand that the institutions or individuals named above cannot deny or refuse to provide treatment, payment, membership or eligibility for AHCC benefits if I refuse to sign this Authorization.

I understand that, once information is disclosed pursuant to this Authorization, it is possible that it could be disclosed by the entity that receives it for authorized purposes under the HIPAA privacy rule.

By signing the member registration form, you indicate that you have read and understood the Alert for Electronic Communications and agree that email messages may include protected health information about me/the patient/member, whenever necessary.

As stated above, if you have any questions, please reach out to us directly via this website, in person at our clinic, or by calling our front office and asking for Jason at 509-823-4650.