Johnson Co. School Telehealth Enrollment Packet

Dear Parent Or Guardian

We are excited to announce that ARH’s ConnectedCare School Program is available at your child’s school. You may have heard this referred to as “Telemedicine”. School nurses and medical staff have been trained to work with a provider online via a safe and secure computer screen and equipment to see students if needed during the day while at school. We can treat illnesses, provide urgent care and help students manage already known medical conditions. We then work with the parent or guardian, the school nurses and your child’s primary care physician to provide the best care possible. If your student is seen at school and will need medication, it can be called in to the pharmacy you normally use. Each student is encouraged to utilize this service. Your insurance will be billed just as it is when you visit your physician and if you have a copay, you will receive a bill in the mail for your copay amount. We also bill Medicaid. If your child is uninsured, we will work with you to ensure that he/she receives the same affordable care as well. Appointments may be scheduled at the medical unit for your child’s school. Nurses will always call a parent or guardian before scheduling your student to see one of our providers. In order to do this for your child, we need you to complete the following health questionnaire and registration form. Please be sure to complete these forms in their entirety, sign and submit.

We can diagnose and treat:
- sinus congestion
- cough
- colds
- fever
- earaches
- sore throats
- common allergies
- conjunctivitis (“pink eye”)
- rashes/skin irritations
- many other common conditions and illnesses
If your child does not have a fever and is not diagnosed with a contagious condition, he/she will be allowed to finish their day at school. Any recommended prescriptions will be sent to your pharmacy. A copy of the visit note will be faxed to your primary care provider. Parents will be contacted with a post-visit follow-up and can view a visit summary by registering for a MyARHChart patient portal account at www.arh.org/myarhchart.

We look forward to assisting you and your student by providing health care services at their school. Parents are encouraged to contact ARH with medical concerns so that we can work together to provide the best care for each student. We are always open to questions or concerns and welcome your feedback. Please visit our website, email or call (606) 789-6464 if you need additional information.

Sincerely,

The ARH ConnectedCare School Program Team

ARH ConnectedCare Schools Consent For Treatment
Patient Name*

First NameMiddle NameLast Name
Patient's Date Of Birth*

MonthDayYear
Patient's School*
School Attending/Employed Type*
Please select the school year for which you are enrolling*

2024-2025 (current school year)
Participation*

I am a staff member or student over age 18 enrolling myself in the ARH ConnectedCare School programI am a parent/guardian enrolling my child in the ARH ConnectedCare School programI do not wish to participate in the ARH ConnectedCare School program
Participation Agreement*

If the school nurse is unable to contact me by telephone when my child is ill, I give permission to have an Appalachian Regional Healthcare provider examine my child, which includes testing for strep throat/flu as needed and/or sending prescription medications to the pharmacy identified on the Student Information Form.The school nurse must contact me by telephone and receive verbal consent before an Appalachian Regional Healthcare provider may exam my child, which includes testing for strep throat/flu as needed and/or sending prescription medications to the pharmacy I identified on the Student Information Form.
I consent to myself/my child being examined by ARH providers and Johnson Co. school nurses through a secure face-to-face video visit, which includes peripheral devices, and tests deemed necessary for treatment of my/my child's condition. I understand that I could instead request an in-office visit with a provider.

I understand that under federal and state law, minors may obtain treatment for venereal disease, alcohol and other drug abuse or addiction, contraception, pregnancy, or childbirth, all without the consent of or notification to the parent, or guardian of such minor patient (KRS 214.185). The health records for these services are also protected from disclosure. As such, a special permission for those services is not included.

I acknowledge the risks, benefits, and alternatives to my/my child receiving care via video visit and understand that if my/my child's condition or technology used for the video visit limits the provider's ability to provide a treatment plan, I/my child will be referred to the appropriate provider.

I authorize ARH to create a MyChart account for me/my child. This will allow me to view a treatment plan and visit summary from me/my child's video visit.

I acknowledge I've reviewed the Notice of Privacy Practices (HIPAA Policy) found on arh.org. If there is any dispute between myself and ARH, Kentucky law will govern.

I understand I can revoke this authorization at any time by submitting a written request to the ARH ConnectedCare School Program.

Authorize for Release of Medical Information

I hereby authorize the release of medical information as necessary to me/my child's primary care provider listed on the medical information form. Unless otherwise indicated, this authorization extends to such psychiatric, alcohol or drug abuse, and HIV related diagnosis information, if any, as may be contained in the clinic records. I understand that I have the authority to release the above reference medical records. Further, I release ARH and any related corporations or affiliates from any liability resulting from the release of these medical records and agree to identify and hold them harmless from any such liability.

I have read the above and understand that items above as it applies to me/my child. I verify I have received a Notice of Privacy Practices (45 CFR 164.520 (2) (ii)) and Bill of Rights.
Patient or Parent/Guardian Signature *

Clear
Signer's Name *

First NameLast Name
Date*

MonthDayYear
Patient Phone Number (parent or legal guardian if patient is a minor)*
Please enter a valid phone number.
Email to MyChart (Patient Portal) for my/my child's health record*
example@example.com

Minor students must have parent/guardian permission to be seen in ARH’s ConnectedCare School Program
PATIENT INFORMATION
Legal Name*

First NameMiddle NameLast Name
Preferred Name*
Date of Birth*

MonthDayYear
Birth Sex*
Social Security Number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact #*
Please enter a valid phone number.
Preferred Contact Type*
Alt Phone #*
Please enter a valid phone number.
Alt Contact Type*
I authorize ARH or the Johnson Co. School District to leave messages on answering machine/voicemail of phone numbers listed above:*

YesNo
Primary Care Physician*
City*
Preferred Pharmacy*
City*
If using the ARH Paintsville Pharmacy would you like to enroll in FREE same day home delivery?

YesNo
Delivery Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Language*
Race*
Ethnicity

HispanicNon-Hispanic
Patient's Marital Status*
Email*
example@example.com
Emergency Contact*

First NameLast Name
Relationship To Patient*
Emergency Contact #*
Please enter a valid phone number.
Alt Emergency Phone #
Please enter a valid phone number.
PERSON RESPONSIBLE FOR PATIENT’S ACCOUNT

(i.e. Guarantor, Parent, Guardian, etc.)
Legal Name*

First NameMiddle NameLast Name
Relationship To Patient*
Date of Birth*

MonthDayYear
Birth Sex*
Social Security Number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone #*
Please enter a valid phone number.
Contact Phone # Type*
Alt Phone #*
Please enter a valid phone number.
Alt Phone # Type*
INSURANCE
Does the patient have insurance?*

YesNo
Primary Insurance:
Subscriber's Name*

First NameMiddle NameLast Name
Relationship To Patient*
Date of Birth*

MonthDayYear
Social Security Number*
Insurance Company*
Policy ID #*
Group #*
Secondary Insurance If Applicable:
Subscriber's Name

First NameMiddle NameLast Name
Relationship To Patient
Date of Birth

MonthDayYear
Social Security Number
Insurance Company
Policy ID #
Group #

VIRTUAL CARE CONSENT FORM
Patient Label
Patient Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Site Where Patient Is Seen Via Virtual Care:
Virtual Care will be used for the following departmental/specialty services:
INTRODUCTION
Virtual care is healthcare provided by any means other than an in-person visit. In virtual care services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered virtual care services.

You are going to have a clinical encounter using videoconferencing technology. You will be able to see and hear the provider and they will be able to see and hear you, just as if you were in the same room. This information may be used for diagnosis, therapy, follow-up and/or education.

Expected Benefits:

• Improved access to care. Patients can get services without leaving their local community.
• Patient remains closer to home, working with local healthcare providers to maintain continuity of care.
• Reduced need to travel for the patient or other provider.

The Process:

You will be introduced to the provider and anyone else who is in the room with the provider. You may ask questions of the provider or any virtual care staff in the room with you if you are unsure of what is happening. If you are not comfortable with seeing a provider on videoconference technology, you may reject the use of the technology and schedule a traditional in-person encounter at any time. Safety measures are being implemented to insure that this videoconference is secure, and no part of the encounter will be recorded without your written consent.

Possible Risks:

There are potential risks associated with the use of virtual care which include, but may not be limited to:
• A provider may determine that the virtual care encounter is not yielding sufficient information to make an appropriate clinical decision.
• Technology problems may delay medical evaluation and treatment for today’s encounter.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
• For direct-to-consumer virtual care patients:

• Lack of privacy at the patient’s location or because the patient may use a shared device.
• Interruption of the visit due to local factors or technology problems.

By Signing this Form, I understand the following:
1. The laws that protect privacy and confidentiality of medical information also apply to virtual care, and that no information obtained in the use of virtual care which identifies me will be disclosed to researchers or other entities without my consent.
2. I have the right to withdraw my consent to the use of virtual care in the course of my care at any time, without affecting my rights to future care or treatment.
3. If the provider believes I would be better served by a traditional in-person encounter, they may, at any time stop the virtual visit and schedule an in-person visit
4. Electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community
5. I may expect the anticipated benefits from the use of virtual care in my care, but that no results can be guaranteed or assured.
6. This consent is for all visits that include virtual care and is valid for up to one year.
7. I agree that I am responsible for Appalachian Regional Healthcare, Inc., for charges resulting from the services rendered using videoconferencing technology at their prevailing rates.
Patient Consent to the Use of Telemedicine:

I have read and understand the information provided above regarding virtual care, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of virtual care in my care.

I hereby authorize Appalachian Regional Healthcare to use telemedicine in the course of my diagnosis and treatment.
Signature of Patient (or authorized person)*

Clear
Signer's Name *

First NameLast Name
Date*

MonthDayYear
If authorized signer, relationship to patient:

PATIENT RIGHTS & RESPONSIBILITIES
PATIENT RIGHTS

YOU, HAVE THE RIGHT TO:
1. Seek and receive necessary healthcare regardless of your age, gender, race, national origin, religion, sexual orientation, or disabilities.
2. Receive considerate, respectful and compassionate care with dignity and comfort, including consideration of your personal time, values, and beliefs.
3. Be informed about your health status, treatment, and results of care, including unanticipated outcomes, and what you can expect with your illness in terms you can understand.
4. Have a family member or representative of your choice or your own physician notified promptly of your admission to the hospital. Please tell your nurse if you wish someone to be notified of your admission.
5. Participate in the development and implementation of your plan of care, and to make decisions regarding that care. Should you be unable to participate in your care and treatment, your rights are to be exercised by your designated representative.
6. Receive from your physician information necessary to make treatment decisions. Except in emergencies, such inFormction should include, but notbe limited to, the specific procedure and/or treatment, associated risks, and the medically significant alternatives for core.
7. Know the identity and professional status of people providing care, including the doctor responsible for your care and treatment.
8. Have information communicated to you in a manner that you can understand. If needed, alternative methods of communication will be
  provided (e.g. large print materials, interpreters, second language materials).
9. Privacy concerning your medical treatment including the right to personal privacy during personal hygiene activities during medical or nursing treatments and when requested as appropriate. You also have the right to be interviewed and examined in private, and have a member of the same sex present during a physical examination
10. Expect that all communications and records pertaining to your care, including the source of payment for treatment, will be treated as confidential.
11. Inspect and obtain a copy of the information contained in your medical records as permitted by law. We will actively seek to meet your request as quickly as possible.
12. Be free from verbal or physical abuse, negligence or harassment while hospitalized.
13. Be free from the use of seclusion and restraints as a means of coercion convenience or retaliation by staff IF restraints are used they will be used only if clinically required and in accordance with your plan of care Restraints may be used only as a last resort and in the least restrictive manner possible to protect you and others from harm. -
14. Expect that, within its capacity, the hospital will make a reasonable response to your request for services. The hospital must provide evaluation, service and/or referral as indicated by the urgency of the case. When medically permissible, you may be transferred after you have received complete information and explanation concerning the need to transfer.
15. Expect reasonable safety in as.far as the hospital practices and environment is concerned.
16. Know about any relationships between Appalachian Regional Healthcare and other healthcare and education institutions as it affects the care provided You also have the right to be told of any professional relationships among individuals who are treating you
17. File complaints and grievances about your care, or any aspect of your rights without the fear of retaliation You can file a complaint with the state agency directly, in addition to or instead of using the hospital's process. Should you wish to contact the state agency directly, the nursing supervisor on duty will provide a phone number and address for you.
18. Accept, refuse, or stop/withdraw treatment to the extent permitted by law, and to be informed of the medical consequences of your action.
19. Leave the hospital against medical advice Please note that leaving against medical advice may pose health risks and may result in denial of reimbursement by third-party payers.
20. Formulate an advance directive, which expresses your wishes concerning treatment in the event you become incapacitated. Advance directives may include a living will, a durable power of attorney, or similar documents conveying your preferences. Such advance directives will be hdnored to the extent permitted by law. Should you desire additional information, need the necessary forms and/or assistance to complete an advance directive, contact the nursing staff member on duty. -
21. Access protective services, which can include protective privacy, guardianship and advocacy services, and child or adult protective services. Should you or your family desire additional information, or require assistance in determining the need for these services, contact the nursing staff member on duty.
22. If you or a family member needs to discuss an ethical issue related to your care, contact a nursing supervisor who will relay this to the hospital's Ethics Corn m ittee.
23. Have your pain assessed and to be involved in decisions about managing your pain. We ask that you notify your nurse immediately when pain first begins, help your doctor and nurse assess your pain, and tell your doctor or nurse if your pain is or is not relieved.
24. Religious and spiritual services when requested Should you desire pastoral services contact the nursing staff member on duty
25. Refuse to talk with or see anyone not officially connected with the hospital or not directly involved in your care.
26. Expect reasonable continuity of care upon discharge. We will assist with follow-up appointments and/or referrals as necessary.
27. Examine and receive an explanation of your bill, regardless of the payment source(s), including available payment methods.
28. Know the hospital's rules and regulations that apply to your conduct as a patient.
29. NEW! You (adult patients) have the right to choose your visitors. These visitors do not have to be related by marriage or blood and will be given the same visitation privileges as an immediate family member.
PATIENT RESPONSIBILITIES

YOU, OR YOU AND YOUR FAMILY, ARE RESPONSIBLE FOR:
1. Wearing your hospital I.D. bracelet at all times.
2. Providing to the best of your knowledge accurate and complete information about present health problems past illnesses, hospitalization, medications, and other matters relating to your health.
3. Reporting perceived risks in your care and any unexpected changes in your condition to your nurse and/or physician
4. Following the treatment plan recommended by your physician and nurse.
5. Your actions if you refuse treatment or do not follow the physician's instructions.
6. Asking questions when you do not understand what you have been told about your care or what you are expected to do.
7. Asking your care provider to arrange for an interpreter if you are deaf, hearing impaired, or if English is not your primary language.
8. Ensuring the financial obligations of your healthcare are fulfilled as prohiptly as possible.
9. Following hospital rules and regulations affecting your care and conduct.
10. Being considerate of the rights of other patients and hospital personnel, for assisting in the control of noise and number of visitors, and adhering to the hospital's no smoking policy.
VOICING A COMPLAINT

We hope that your experience is positive and conducive4o healing We understand however if you feel there has been a certain aspect of your care that could be improved upon ARH encourages this feedback as we view it as useful in making our hospital better We encourage you to contact us directly if you have a complaint or concern about the services you are receiving from our facility and its staff. IF you have a complaint, please contact the nursing supervisor.

You also have the right to contact the state hospital agency of licensing and regulation instead of or in addition to using the internal complaint process In Kentucky, complaints can be made by contacting the Office of Inspector General Southern Enforcement Branch and asking for the complaint coordinator at (606) 330-2030. In West Virginia, contact the Office of Heath Facility Licerisure and Certification (OHFI.AC) at (304) 558-0050.

NOTICE OF PRIVACY PRACTICES
Patient Name*

First NameLast Name
Sex*
Date Of Birth*

MonthDayYear
Age*
APPALACHIAN REGIONAL HEALTHCARE, INC. ("ARH") AND ALL ARH SUBSIDIARIES, D/B As, or other FACILITIES PROVIDING HEALTH CARE OR HEALTH CARE-RELATED SERVICES AS PART OF THE ARH ORGANIZED HEALTH CARE ARRANGEMENT DEFINED UNDER 45 CFR 164.501, et seq:

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY OUR FACILITIES AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Appalachian Regional Healthcare, Inc. ("ARH") is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and your rights with respect to protect health information. ARH is required by law to abide by the terms of this Notice.

WHO WILL FOLLOW THIS NOTICE

All employees, staff, including medical staff and other personnel of Appalachian Regional Healthcare, Inc. will follow these privacy policies.

HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED:

Treatments:

We will use your medical information to provide you with medical treatment or services. For example, your medical information may be used by the doctor, nurse, pharmacists, technicians, medical students, or other personnel who are involved in taking care of you. ARH may also disclose medical information about you to people outside of the hospital who may be involved in your medical care.

Payment:

We may use and disclose medical information about you so that we may bill for treatment and services you receive at ARH facilities. For example, we may need to give information about surgery you receive to your healthcare plan so that the insurance plan will pay us or reimburse you for your care. We may also share information with your healthcare plan in order to receive approval or to determine if your plan will pay for treatment.

Healthcare Operations:

We may use and disclose medical information about you for operation of the Hospital and entities involved in an organized healthcare arrangement. These uses and disclosures are necessary to run our healthcare facilities and to make sure that our patients receive quality care. For example, we may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you or to evaluate services being offered by ARH facilities. We may also disclose information to doctors, nurses, technicians, nursing and medical students and other personnel for review and learning purposes. We may combine medical information with other similar organizations to compare how we are doing and where we can make improvements in the care and services offered. We may remove information that identifies you from this set of medical information so others may use it to study health care without knowing the specific patients information.

We may also use and disclose your information, in accordance with federal and state laws, for the following purposes:

Appointment Reminders.

We may contact you to provide appointment reminders.

Treatment Alternatives.

We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services.

We may use and disclose medical information to tell you about health-related benefits or services provided through ARH that may be of interest to you.

Fundraising Activities.
- We may use medical information about you to contact you in an effort to raise money for ARH and its operations. We may disclose medical information to a foundation related to the hospital so that the foundation may contact you in raising money for the hospital. We would only release limited information such as contact information, including your name, address, phone number and the dates you received treatment or services at an ARH facility. Any such communication addressed to you would contain instructions describing how you may "opt out" of receiving these fundraising communications.
Facility Directories.
- Unless you object, we will include your name, your location at the ARH facility where you are receiving treatment, your condition described in general terms, and your religious affiliation, in our directory of individuals. The directory information, except for your religious affiliation, will then be released to people who ask for you by name. Unless you object, religious affiliation may be given to members of the clergy, even if they do not ask for you by name. You may specifically request that we do not include you in the directory when you register.
Family and Friends.
- Unless you object, we may disclose medical information to family members, other relatives or close personal friends when the medical information is directly relevant to that person's involvement with your care. We may release information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay or your care.
Notification.

Unless you object, we may use or disclose your medical information to notify a family member, a personal representative or another person responsible for your care of your location, general condition or death.

Psychotherapy Notes.

Most uses and disclosures of psychotherapy notes will only be made with your authorization. For example, without your authorization, these notes may be only used for treatment and training purposes, or for use in your treatment by the original writer of the notes.

Research.
- We may use or disclose your medical information or certain research purposes if an Institutional Review Board or privacy board was altered or waived individual authorization, the review is prepatory to research, or the research is limited to information about a descendent. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We will always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are or will be involved in your care.
Business Associates.

We may disclose your health information to a business associate with whom we contact to provide services on our behalf. To protect your health information, we require our business associate to appropriately safeguard the health information of our patients.

Public Safety.
- We may use or disclose your medical information to prevent or lessen a serious threat to your health and safety or the health and safety of another person or to the public.
SPECIAL SITUATIONS: The following situations may result in additional uses and disclosure of health information by Appalachian Regional Healthcare.

Workers' Compensation.

We may use or disclose your medical information as authorized by laws relating to workers' compensation or similar programs.

Organ and Tissue Donation.
- If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization, or as otherwise required by state or federal law.
Coroners, Medical Examiners and Funeral Directors.

We may disclose your medical information to a coroner, medical examiner or a funeral director.

Health Oversight Activities.
- We may disclose medical information to a health oversight agency for activities authorized by law. These activities include, for example, audits, investigations, inspections and licensure activity. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights law.
Disclosure to the Department of Health and Human Services.
- We may use disclose medical information when required by the United State Department of Health and Human Services as part of an investigation or determination of our compliance with relevant laws.
Legal Proceedings.

We may disclose your medical information in the course of certain judicial or administrative proceedings such as in a suit or criminal action.

Law Enforcement.
- We may disclose your medical information if asked to do so by a law enforcement official:
  - In response to a court order, subpoena, warrant, summons or similar process;In response to a court order, subpoena, warrant, summons or similar process;
  - To Identify or locate a suspect, fugitive, material witness, or missing person;
  - About the victim of a crime if we are unable to obtain the person's agreement;
  - About a death we believe may be the result of criminal conduct;
  - About criminal conduct at an Appalachian Regional Healthcare facility;
  - 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;
  - To Children and Family Services;
Public Health Risks.
- We may disclose to authorized public health or government officials medical information about you for public health activities. These activities generally include the following:
  - to prevent or control disease, injury or disability; to report disease or injury;
  - to report births and deaths;
  - to report child abuse or neglect;
  - to report reactions to medications and food or problems with products;
  - to notify people or recalls or replacements of products they may be using;
  - to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  - to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law;
Diseaster Relief.
- We may disclose your medical information to a public or private entity, such as the American Red Cross, for the purpose of coordinating with that entity to assist in disaster relief efforts.
OTHER USES OF MEDICAL INFORMATION

Other uses and disclosure of medical information not covered by this notice or the laws that apply to us will be made only with a patient's written permission. If you provide us with permission to use or disclose your medical information, you may revoke that permission in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by the original written authorization. You understand we are unable to take back any disclosure we have already made with your permission, and we are required to retain our records of the care we provided to patients.

For example, your medical information will be used or disclosed for the following purposes ONLY with your written authorization:
- Any use or disclosure for marketing purposes
- Any use or disclosure which would constitute the scale of protected health information
- Most uses and disclosures of psychotherapy notes
- Any use or disclosure not specifically set forth herein.
To request a Revocation of Authorization form, you may contact the Health Information Department at the hospital or facility. You may also contact: Chief Privacy Officer, ARH System Center, 100 Airport Gardens Road, Hazard, KY 41701 or the ARH Office of Legal Affairs at 606-439-6936 to request a form.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights with respect to your medical information:
- You may ask us to restrict certain uses and disclosures of your medical information. We are not required to agree to all requests for restriction, but if we do, we will honor it.
- You also have the right to restrict the disclosure of your protected health information to your insurance or other health plan if you have paid for the services you receive out of your own pocket.
- You have the right to receive communications from us in a confidential manner. To request confidential communication, you must make a request in writing to the Health Information Dept. at the hospital or facility where your medical records are maintained. A request must specify how or where you wish to be contacted. ARH will make efforts to accommodate all reasonable requests.
- Generally, you may inspect and copy your medical information. You can ask to receive an electronic or paper copy of your medical record. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records.
- You may ask us to amend your medical information. We may deny your request for certain specific reasons. If we deny your request, we will provide you with a written explanation for the denial and information regarding further rights you may have.
- You have the right to receive an accounting of the disclosures of your medical information made by ARH during the last six years except for disclosures for treatment, payment or healthcare operations, other disclosures listed in this notice, disclosures with you have authorized, and certain other specific disclosure types.
- You may request a paper copy of this Notice of Privacy Practices. You may ask us for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
- Right to Breach Notification - You have the right to be notified of any breach of your unsecured healthcare information.
- You have the right to choose someone to act for you - If you have given someone power of attorney of if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.
- You have the right to complain to us or the Untitled States Department of Health and Human Services if you believe that we have violated your privacy rights. If you choose to file a complaint, you will not be retaliated against in any way. To complain to us, or if you would like further information regarding your rights or about the uses and disclosures of your medical information, you may contact the Chief Regulatory Affairs Officer ("CCRAO") at the local ARH facility where you received your treatment, or you may Contact: Chief Privacy officer, ARH System Center, 100 Airport Gardens Road, Hazard, KY 41701 or the ARH Office of Legal Affairs at 606-439-6936.
REVISION OF NOTICE OF PRIVACY PRACTICES

We reserve the right to change to change the terms of this Notice, making any revision applicable to all the protected health information we maintain. If we revise the terms of this Notice, we will post a revised notice at our facilities and will make copies of the revised Notice of Privacy Policy Practices available to our patients upon request.

NONDISCRIMINATION STATEMENT

Appalachian Regional Healthcare, Inc. complies with applicable Federal civil rights low and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Appalachian Regional Healthcare, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, naionalidad, edad, discapacidad o sexo.

ACKNOWLEDGEMENT:

I hereby acknowledge that I have received and had an opportunity to ask questions concerning the ARH Notice of Privacy Practices.
Patient or Patient's Representative*

Clear
Signer's Name *

First NameLast Name
Date*

MonthDayYear
Representative's Relationship to Patient

AIDS.. WHAT YOU SHOULD KNOW*
Patient Name*

First NameLast Name
Sex*
Date Of Birth*

MonthDayYear
Age*
What is AIDS?

Acquired immunodeficiency syndrome, AIDS, is a disease caused by a virus that destroys the body's natural ability to
fight illness. This allows diseases such as cancer and infections such as pneumonia to invade that body and cause death. At this time, there is no cure or vaccine for AIDS.

How does AIDS spread?

The human immunodeficiency virus (HIV) which causes AIDS is transmitted through blood, semen, and vaginal secretions. The main ways the virus is spread includes:
- Having sex (anal, oral or vaginal intercourse) with an infected person when blood, semen, or cervical / vaginal secretions are exchanged;
- Sharing a syringe / needle with someone who is infected;
- Being born with the virus if your mother has been infected;
- Receiving contaminated blood or blood products, organ / tissue transplants, and artificial insemination from an infected person (rare now since testing for HIV antibodies began).
How can I prevent getting AIDS?

The way to prevent getting AIDS is to avoid those behaviors which provide an opportunity for the virus to be passed from one person to another. A few simple rules apply:
- Do not have sex with someone who has AIDS or is infected with the virus;
  When unsure of a sex partner's health status, practice safe sex by using latex condom, female condom, or dental dam;
- Limit the number of sexual partners to reduce your chances of exposure to the virus;
- Do not share syringes or needles with anyone;
- You should be tested for HIV if you are pregnant or plan to be pregnant;
- Avoid alcohol and other drugs which affect judgement and make one more likely to engage in risky behavior;
- Educate yourself and others about HIV infection and AIDS.
Other facts about AIDS
- Donating blood is NOT SAFE.
- The virus is NOT spread by casual contact such as touching, coughing, sneezing, or using bathrooms, water fountains, swimming pools, and telephones that an infected person has used.
- Birth control pills and diaphragms DO NOT protect against AIDS.
- A person can be infected with HIV / AIDS and be able to transmit it before he or she shows symptoms of AIDS.
- A blood test is one way to know whether or not a person is infected.
- For additional information or advice regarding HIV / AIDS, contact your physician or other healthcare professional.
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*This information corresponds with Center Disease Control recommendations and is provided in compliance with Kentucky State Law (KRS 214.620).

ADVANCE DIRECTIVES... WHAT YOU SHOULD KNOW*
Patient Name*

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Sex*
Date Of Birth*

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Age*
What is an Advance Directive?

An advance directive is a legal document, such as a living will, which would help to guide your family and your doctor, if you should become terminally ill and/or unable to communicate your wishes about medical treatment to them.

What are your legal rights concerning advance directives?

Federal and state legislation assure you of the right to accept or refuse medical care. These laws also give you the right to prepare an advance directive such as a living will, medical power of attorney, or healthcare surrogate designation.

"It is the policy of ARH to accede to the decisions of competent adults, in accordance with applicable Federal and/or State laws regarding the implementation of such rights."

How can you learn more about advance directives?

Your physician, the ARH staff, or your attorney can provide you with more information or assistance.

Where should an advance directive be kept?
- It is your responsibility to give a copy of your advance directive to your physician and to notify your family of your advance directive's location
- It is also your responsibility to inform those to whom you have given copies if you change or revoke your advance directive
- Keep your advance directive with other personal papers in a safe, convenient location, at home.
Do you have an advance directive?*

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If yes, where is the document?
Revocation*

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Date*

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Have you provided the hospital with the most recent copy of your advance directive?*

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Are you interested in speaking with someone about advance directives?*

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	Medication Name (prescriptions, over the counter & vitamins)	Dose	How often taken?	Why is medication taken?
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VIRTUAL CARE CONSENT FORM

INTRODUCTION

PATIENT RIGHTS & RESPONSIBILITIES

NOTICE OF PRIVACY PRACTICES

AIDS.. WHAT YOU SHOULD KNOW*

ADVANCE DIRECTIVES... WHAT YOU SHOULD KNOW*