By signing below, I acknowledge and agree that I have the legal authority as the parent or legal guardian of the Minor Child to sign this Consent and that I:

• authorize The Nebraska Medical Center and/or University of Nebraska Medical Center and any of their affiliates or subcontractors acting on their behalf (collectively UNMC) to transport a SARS-CoV-2 saliva test (COVID-19 Test) sample that the Minor Child collects and provides to UNMC and to test the sample for the presence of COVID-19;
• understand the following:
• One World Community Health Centers or Charles Drew Health Centers will receive the Minor Child’s COVID-19 Test results via encrypted email;
• In the event of a positive result, One World or Charles Drew will contact me;
• UNMC also will send the Minor Child’s COVID-19 Test results to me by encrypted email;
• Written COVID-19 Test results or a copy thereof will be retained by UNMC and One World or Charles Drew, and made available to me upon request; and
• COVID-19 Test results and related protected health information (e.g., name and address, and any other demographic or clinical information required by such officials) will be shared with the local/state/federal public health departments and authorities as required by applicable law.

I hereby waive, release, hold harmless, and promise not to sue UNMC, OPS, and One World or Charles Drew, and any of their respective employees, owners, and representatives, regarding any claim I may have in connection with the COVID-19 Test.

You must select yes in order to proceed with testing.

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Al firmar a continuación, reconozco y acepto que tengo la autoridad legal como padre o tutor legal del Niño Menor para firmar este Consentimiento y que:

• Autorizo al Nebraska Medical Center y/o al University of Nebraska Medical Center y cualquiera de sus afiliados o subcontratistas actuando en su nombre (colectivamente UNMC) para transportar una muestra de prueba de saliva SARS-CoV-2 (prueba para el COVID-19) que el niño menor de edad recolecte y proporcione a UNMC y para analizar la muestra para detectar la presencia del COVID-19;
• Comprendo lo siguiente:
• One World Community Health Centers o Charles Drew Health Centers recibirá los resultados de la prueba para el COVID-19 del niño menor de edad a través de un correo electrónico cifrado;
• En caso de un resultado positivo, One World o Charles Drew se pondrá en contacto conmigo;
• UNMC también me enviará los resultados de la prueba para el COVID-19 del menor de edad a través de un correo electrónico cifrado;
• Los resultados escritos de la prueba para el COVID-19 o una copia de los mismos serán retenidos por UNMC y One World o Charles Drew, y estarán disponibles para mí cuando los solicite; y
• Los resultados de la prueba COVID-19 y la información de salud protegida relacionada (por ejemplo, nombre y dirección, y cualquier otra información demográfica o médica requerida por dichos funcionarios) se compartirán con los departamentos locales/estatales/federales de salud pública y autoridades según lo requiera la ley aplicable.

Por la presente renuncio, libero, eximo de responsabilidad, y prometo no demandar a UNMC, a OPS y a One World o Charles Drew, ni a ninguno de sus respectivos empleados, propietarios, y representantes, con respecto a cualquier reclamo que pueda tener en relación con la prueba para el COVID-19.

Debe seleccionar si para poder proceder con la prueba

Parent/Guardian First Name *

Parent/Guardian Last Name *

I request and consent to receive my results via encrypted email.

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.

Health Center Practice Covered by this Notice

If you have questions about this notice, please contact the Charles Drew Health Center, Inc. Privacy Officer at (402)-457-1202 or Angeline.Larson@charlesdrew.com

Notice of Privacy Practices (The Notice) – A written notice in compliance with the requirements of Health Insurance Portability and Accountability Act(HIPAA), and the Health Information Technology for Economic and Clinical Health Act (HITECH), enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009, made available from Charles Drew Health Center, Inc. to any individual or the individual’s personal representative at the first delivery of services, or at the individual’s next visit following a revision of the Notice, that describes the users and disclosures of protected health information that may be made by Charles Drew Health Center, Inc. and the individual’s rights and Charles Drew Health Center, Inc. legal duties with respect to protected health information.

Protected Health Information (PHI)

– Individually identified health information that is transmitted or maintained in any form or medium, including electronic media. Protected health information does not include employment records held by Charles Drew Health Center, Inc. in its role as an employer.

How We May Use or Disclose Your Health Information

The following examples describe different ways we may use or disclose your health information. These examples are not meant to be exhaustive. We are permitted by law to use and disclose your health information for the following purposes:

For Treatment. We will use your health information to provide you with health care treatment and to coordinate or manage services with other health care providers, including third parties. We may disclose all or any portion of your health information to your attending physician, consulting physician(s), nurses, technicians, or other facility or health care personnel who have a legitimate need for such information in order to take care of you. Different departments of the facility will share your health information in order to coordinate the health care services you need, such as prescriptions, lab work and X-rays. We may disclose your health information to family members, friends, guardians or personal representatives who are involved with your health care. We may also use and disclose your health information to contact you for appointment reminders and to provide you with information about possible treatment options or alternatives and other health related benefits and services. We also may disclose your health information to people outside the facility who may be involved in your health care after you leave the facility, such as other physicians involved in your care, specialty hospitals, skilled nursing care facilities, and other health care-related services. We may use and disclose your health information to prescription networks to obtain your prescription benefits from payers, to obtain your medication history from different health care providers in the community such as pharmacies, and to send your prescriptions electronically to your pharmacy.

Payment. We will use and disclose your health information for activities that are necessary to receive payment for our services, such as determining insurance coverage, billing, payment and collection, claims management, and medical data processing. For example, we may tell your health plan about a treatment you are planning in order to receive approval or to determine whether your plan will pay for the proposed treatment. We may disclose your health information to other health care providers so they can receive payment for health care services that they provided to you, such as your personal physician, and other physicians involved in your health care, or ambulance services. We may also give information to other third parties or individuals who are responsible for payment for your health care, such as the named insured under the health policy who will receive an explanation of benefits (EOB) for all beneficiaries who are covered under the insured’s plan.

Health Care Operations. We may use and disclose your health information for routine facility operations, such as business planning and development, quality review of services provided, internal auditing, accreditation, certification, licensing or credentialing activities (including the licensing or credentialing activities of health care professionals), education for staff, assessing your satisfaction with our services, and to other health care entities that have a relationship with you and need the information for operational purposes. We may use and disclose your health information to the external agencies responsible for oversight of health care activities such as the The Joint Commission, external quality assurance and peer review organizations, and credentialing organizations. We may also disclose health information to business associates we have contracted with to perform services for or on our behalf such as patient satisfaction survey organizations. We may also disclose your health information to medical device manufacturers or pharmaceutical companies in order for those companies to carry out their legal obligations to state and federal agencies.

Disclosure to Business Associates. We may disclosure your protected health information to our third-party service providers (called, “business associates”) that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use a business associates to assist us in maintain our practice management software. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Appointment Reminders. We may use or disclose your health information when contacting you to remind you of an appointment. We may contact you by using a postcard, letter, phone call, voice message, or email.

Nebraska Health Information Initiative. Charles Drew Health Center, Inc. participates in the Nebraska Health Information Initiative (“NeHII”), a statewide internet-based health information exchange. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may ‘opt-out’ and prevent searching of your health information available through NeHII, by calling 1-866-978-1799, or completing and submitting an ‘Opt-Out’ form to NeHII, by mail, fax or through their website at www.nehii.org.

Future Communication. We may provide communications to you with newsletters or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community based initiatives or activities in which our facility is participating.

USES AND DISCLOSURES THAT ARE REQUIRED OR PERMITTED BY LAW

Public Health Activities. We may disclose your health information to public health officials for activities such as for the prevention or control of communicable disease, bioterrorism, injury, or disability; to report births and deaths; to report suspected child, elder, or spouse abuse or neglect; to report reactions to medications or problems with medical products; to report information to the federal Centers for Disease Control or to authorized national or state cancer registries for their data aggregation.

Disaster Relief Efforts. We may disclose your health information to an entity assisting in a disaster relief effort, such as the American Red Cross, so that your family can be notified about your condition and location.

Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. Such agencies include federal Centers for Medicare and Medicaid Services, and state medical or nursing boards. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor activities such as health care treatment and spending, government programs, and compliance with civil rights laws.

Judicial or Administrative Proceeding. We may disclose your health information in response to a legal court or administrative order, a subpoena, discovery request, civil or criminal proceedings, or other lawful processes.

Law Enforcement. We may release your health information if asked to do so by a law enforcement official or if we have a legal obligation to notify the appropriate law enforcement or other agencies: In response to a court order, subpoena, warrant, summons or similar legal process; or Regarding a victim or death of a victim of a crime in limited circumstances; or In emergency circumstances to report a crime, the location or victims of a crime, or the identity, description or location of a person who is alleged to have committed a crime, including crimes that may occur at our facility, such as theft, drug diversion, or attempts to obtain drugs illegally.

Workers’ Compensation. We may release your health information for workers’ compensation benefits or similar programs that provide benefits for work-related injuries or illnesses if you tell us that workers’ compensation is the payer for your visit(s). Your employer or their workers’ compensation carrier may request the entire medical record pertinent to your workers’ compensation claim. This medical record may include details regarding your health history, current medications you are taking, and treatment.

Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority. Inmates. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may release your health information to the institution or law enforcement official. This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Right to Inspect and Copy. You have the right to inspect your health information and receive a copy of medical, billing, or other records that may be used to make decisions about your care. The right to inspect and receive a copy may not apply to psychotherapy visit notes. Your request to inspect and receive a copy of your health information must be submitted in writing. We may charge a fee for document requests to cover the costs of copying, mailing, or other supplies. You have the right to request your health information in electronic format. Charles Drew Health Center, Inc. will provide your health information in the form and format you request, if available or in a mutually agreeable form and format. In limited circumstances we may deny your request to inspect or receive a copy of your health information. If you are denied access to your health information, you may request that the denial be reviewed. A licensed health care professional chosen by Charles Drew Health Center, Inc. will review your request and the denial. The person who conducts the review will not be the same person who denied your request. We will comply with the outcome of the review.

Right to Amend. You have the right to request an amendment to your health information that you believe is incorrect or incomplete. Submit your request in writing, including your reason for the amendment, in the subject line state “Request for Amendment to PHI” and send the request to the medical record custodian. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that: • Was not created by Charles Drew Health Center, Inc. unless the person or entity that created the information is no longer available to make the amendment; • Is not part of the medical information kept by or for Charles Drew Health Center, Inc.; • Is not part of the information that you would be permitted to inspect and copy; or • Is accurate and complete.

Right to Request Confidential Communication. You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you can ask that we only contact you at an alternative location from your home address, such as work, or only contact you by mail instead of by phone. Your request must specify how or where you wish to be contacted. We do not require a reason for the request. We will accommodate all reasonable requests.

Right to Receive Notice of a Privacy Breach. You have the right to receive written notification if Charles Drew Health Center, Inc. discovers a breach of unsecured protected health information involving your health information. Breach means the unauthorized acquisition, access, use, or disclosure of protected health information which compromises the security or privacy of the information.

Right to Paper Copy of This Notice. You have the right to a paper copy of this notice. If you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Charles Drew Health Center, Inc. Privacy Officer.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you and for any information we may receive in the future. We will post a copy of the current notice in the facility and on our web site (if applicable) at www.charlesdrew.com. The notice will contain the effective date. Upon your initial registration to the facility for treatment or health care services as a patient, we will offer you a copy of the notice currently in effect. Whenever the notice is revised, it will be available to you upon request.

You may file a complaint with Charles Drew Health Center, Inc. Privacy Officer at 2915 Grant Street, Omaha, NE 68111 or Angeline.Larson@charlesdrew.com

If you file a complaint, we will not take any action against you or change our treatment of you in any way.

Please read and review each section and sign where prompted.

1. 1. Authorization for Medical Treatment. I do hereby acknowledge, agree, and give my consent for diagnosis, treatment, behavioral health treatment, dental treatment, as deemed necessary by Charles Drew Health Center, Inc. as indicated appropriate by my treating provider, their assistants and/or designees.This Authorization includes, but is not limited to, routine diagnostic procedures, outpatient and inpatient care, laboratory test, x-rays and other tests or procedures. I also authorize copies of the medical records to be released to other physicians and healthcare facilities as deemed necessary by any physician(s) or provider whose care I am under. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as result to examination and treatment received at this Facility. I acknowledge that my care is under the direction of my treating provider and the Charles Drew Health Center, Inc. facility will follow the instructions of my provider(s) in the position in said care.
2. 2. Patient Care. I, the undersigned, agree to uphold my responsibilities to take charge of my health care, working with my provider and maintaining compliance with my providers designated care plan for my health and well being.
3. 3. Personal Valuables. I accept full responsibility for all property in my possession. I understand that Charles Drew Health Center, Inc. maintains no responsibility for property that is personal and in my possession.
4. 4. Duration and Scope. I understand this agreement will be valid for one year (12 months) from the date it is signed, unless I cancel it sooner.This agreement will apply to any care provided to the patient at any Charles Drew Health Center Inc. locations during the next year, unless the care provided requires additional consents by law.
5. 5. Physician and Staff Employment. Some providers at Charles Drew Health Center Inc. may be independent contractors who use Charles Drew Health Center Inc. facilities to provide care to their patients (“Contractors”). As such, these various independent contractors may submit bills for the professional services they provide separate from the bill Charles Drew Health Center Inc. may submit. Contractors are responsible for their own actions and Charles Drew Health Center Inc. is not liable for their actions or failure to act.
6. 6. Assignment of Facility Benefits. I hereby assign all insurance benefits and/or Medicare/ Medicaid benefits to Charles Drew Health Inc. and authorize direct payment to facility.This payment includes all payments for charges incurred during treatment, visit and observation at all clinics for Charles Drew Health Inc. I agree that I am responsible for the financial aspect of my healthcare and will maintain compliance for any and all insurance plans, Medicare/Medicare and any self-pay and/or sliding fee details. A photocopy of this agreement shall be as valid as the original.
7. 7. Assignment of Professional Benefits. I hereby assign all insurance benefits and/or Medicare/ Medicaid benefits to all physician(s), therapist(s), and/or medical professionals providing services to me and authorize direct payment to physician(s) and therapist(s). I agree to pay for any and all charges not paid pursuant to this assignment. A photocopy of this assignment shall be as valid as the original.
8. 8. Authorized Representative. I hereby authorize Charles Drew Health Center Inc. and its facilities, its agents and representatives to act on my behalf to recover benefit claims, appeal adverse benefit determinations, and to take any action deemed necessary to obtain payment for services provided to me by said Facility(s).
9. 9. Statement of Responsibility. I understand that I am financially responsible to Charles Drew Health Center Inc. as the patient, guardian, and conservator or insured for all charges not covered by the above assignments or programs. Charges may include medical insurance deductibles, co-insurance out-of-pocket expenses.
10. 10. Sliding Fee Discount Program Policy. Charles Drew Health Center Inc. has a sliding fee discount program and I may ask about it at any time.There is an application process for sliding fee, and eligibility is based on family size, family income, and other special circumstances. I may request a sliding fee application at any time.
11. 11. Self-Payment. I understand I may choose to not have Charles Drew Health Center Inc. bill my and/or the patient’s insurance for a particular health care item or service provided to the patient, and instead choose to personally pay in full the cost of that health care item or service.To exercise this option, I must notify Charles Drew Health Center Inc. in a timely manner, complete additional forms, and pay all applicable charges promptly and in full.
12. 12. Authorization to Release Information to Insurance Company/Third Party Payer. I hereby authorize Facility(s), any authorized healthcare provider, including Veterans Administration or governmental hospital, any insurance company or other person, institution, or organization to release my medical records to any person, corporation, workers compensation carrier, governmental agency (or representative thereof) which is or may be, liable under any contract or governmental program to this Facility, the patient, or a family member for all or part of the Facility(s) charge.This Facility will endeavor to protect the confidentiality of my medical records. However, the Facility shall not be liable by reason of its release of said medical records or any part thereof when responding in good faith to an apparently valid release. I authorize release of pertinent records to pharmaceutical companies as needed.
13. 13. Non-covered Medicare/Medicaid Services. The Medicare and Medicaid Programs have certain charges that are excluded from coverage, including but not limited to: cosmetic surgery, non-medically related dental surgery, routine diagnostic workups, routine physical exams, and oral drugs. I acknowledge I am financially responsible for all charges incurred if my medical/dental chart indicates for any of the listed treatments or care as listed.
14. 14. Shadowing and Observation. Some people involved in patient’s care may be medical, nursing, or other health care personnel in training. I consent to their participation. Other non-Charles Drew Health Center Inc. staff members may observe the patient’s care. I have the right to request that any of these individuals not participate in or observe the patient’s care and this request will not affect the patient’s care at Charles Drew Health Center Inc.
15. 15. Contact by Phone. By providing Charles Drew Health Center Inc. with my land line and/or cell phone number(s), I give my express consent for Charles Drew Health Center Inc., its contractors, agents, and collection agents to contact me at these numbers, or at any number that I later acquire, and to leave live or pre-recorded messages or to send text messages regarding accounts or services. I understand that for greater efficiency, calls may be delivered by an auto-dialer.
16. 16. Advanced Instructions for Healthcare. I understand that I may indicate in writing (Advanced Directions, i.e. Living Will and Durable Power of Attorney) my desire to receive, select, and/or define medical or surgical treatment or choose non-treatment Charles Drew Health Center Inc. will recognize such instructions in accordance with Nebraska and/or Iowa State law and the Facility(s) policies if either both Advance Direction statement(s) are provided to the Facility(s) so that a copy is filed with any medical record.