907 Georgiana St., Port Angeles, WA 98362 (360) 565-0999 Fax (360) 565-0851

800 N. 5th Avenue, Suite 101, Sequim, WA 98382 (360) 565-0999 Fax: (360) 582-4221

Appointment Reminder

Patient Name: Date of Birth:

Provider:

Appointment Date: Check In Time:

Appointment Address: ❑ 907 Georgiana St. (MOB Building), Port Angeles

❑ 800 N 5th Ave., Suite 101 (MSB Building), Sequim

Please Note:

• Fill out all of the enclosed

forms.

• Return forms to the Primary

Care Clinic as soon as

possible (mail, fax or in person).

• Bring your insurance cards,

photo ID and any Advanced

Healthcare Directive you may

have (IE. POLST form, Durable

Power of Attorney for Healthcare,

etc) to your appointment.

• Please contact us at

(360) 565-0999 if you need to

reschedule or cancel your

appointment.

• The above time has been

reserved especially for you. If

you are unable to use this

appointment, please give us

24 hour notice.

• .If you do not confirm your new patient appointment within 24 hours prior to the.

.appointment, it will be cancelled. .

Thank you for choosing OMP Primary Care Clinic!

Appointment Pack PCC Referral OMP35007 9/21/2020 Yellow

Frequently Asked Questions for

OMP Primary Care Patients

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Please read the following letter about Olympic Medical Physicians

Primary Care Clinic’s approach to prescribing opioid pain medications.

Dear Patient,

Our providers and staff, and many community members are concerned about the high levels of opioid use in our country and in Clallam County.

Like other community providers, we no longer routinely prescribe opiates for non-cancer-related chronic pain. Opioid medication was previously a predominant treatment for chronic non-cancer related pain, but research has shown these substances have led to considerable harms for some patients. Opioids, also known as narcotics, include prescription pain medications. Some examples are Vicodin, OxyContin, Percocet, Ultram, morphine, methadone, oxycodone, hydrocodone, fentanyl, codeine, tramadol, and heroin.

We work closely with our patients currently taking opioid medications to evaluate the appropriateness, safety, and effectiveness of their medication regimen, as well as encourage other non-opiate methods for managing chronic pain. We understand that changes in your medication regimen may be undesirable, but medical research is very clear regarding the risks and lack of long-term benefit of opiate medications.

Medical research shows that using opioids for conditions besides acute pain (which tends to go away in about 10 days) is often not helpful, and can be harmful in many different ways including side effects, opioid dependence, opioid use disorder, and in some cases, death.

Opioid dependence is most easily understood as a person’s desire to avoid withdrawal symptoms. One can develop dependence after taking opioids every day for just two weeks. People who are dependent on opioids become more sensitive to pain, and often feel like they need more pain medicine. It is possible for opioid dependence to lead to opioid use disorder.

Opioid Use Disorder (also known as addiction) is a disease where someone experiences cravings and has trouble controlling drug use. Research shows that many people who have opioid use disorder started out by receiving prescriptions from their health care providers for acute or chronic pain. It is very important to our providers to prevent this condition when possible, and to recognize if the use of opioids has progressed to opioid use disorder because treatment can be made available.

If you have questions about our approach to opioids, we welcome you to ask your provider at your upcoming appointment.

Thank you for trusting Olympic Medical Physicians as your partner in health care.

Sincerely, Angela Larson, MD Medical Director, OMP Primary Care Clinic OMP36313 10/29/2020

Notification of No Show, Late Arrival

and Late Cancellation Policy

Quality care for our patients is our priority. Please take a few minutes to review our no-show policy and sign at

the bottom of the form. If you have any questions please let us know.

This notice addresses the following:

1. When patients do not show for their appointments (“no show”)

2. When patients arrive past their appointment time (“late arrival”)

3. When patients cancel their appointments with less than 24 hrs notice (“late cancellation”)

When these occur, there is a significant negative impact on our practice and on our ability to provide quality

timely care to our patients. These occurrences can negatively impact that patient’s healthcare, take away time

that could be spent with other patients, and increase wait times for the practice.

How to avoid No Shows, Late Arrivals and Late Cancellations:

1. Confirm your appointment – use our Text Messaging service for automatic updates (ask your registrar

for information)

2. Arrive at your confirmed arrival time (this is often a few minutes prior to your appointment time to give

our staff time to update your records and complete your arrival)

3. Give 24 hrs notice for any appointment cancellations.

Consequences to No Shows, Late Arrivals and Late Cancellations

1. You will receive a phone call, or a letter, letting you know we missed you at your appointment time.

2. You will be offered a re-scheduled appointment, but your wait time may be longer.

3. If you miss three or more of your appointments, you may be dismissed from our practice.

I have read and understand the Olympic Medical Physicians No Show, Late Arrival and Late Cancellation notice.

________________________________________ _____________________________

Patient Name Date

OMP20997 5/27/2020

Name:_____________________________________ Date of Birth:__________________Primary Care ReferringProvider:______________________________ Provider:____________________

Medications (include supplements and over the counter drugs)

Name Dose Frequency

Pharmacy/ Local: Mail Order:

Allergies Agent Reaction

Type of surgery Date Reason

Family HistoryRelationship Age Medical Conditions / Cause of death

Mother deceased

Father deceased

Brother(s) #____ deceased

Sisters(s) #____ deceased

Children #____ deceased

Marital Status: Married Single Divorced Widowed Legally Separated

Children: No Yes; if yes, how many children:_____________

Sexually Active: Yes No

Occupation:____________________________________________Smoking/Tobacco: Never Yes, year started:____________ Quit; year quit:_____________

cigarettes: Yes No pks/day:cigars: Yes No cigars/day:

smokeless: Yes No cans/day:Alcohol: Yes No drinks/day:Marijuana: Yes No amt:Street drugs: Yes No type:Caffeine: Yes No type: cups/day:Exercise: Yes No type: amount:

OMP24831 4/23/2019 (Patient History & ROS, OMP) Page 1 of 2

Social History / Habits

Past Surgical History

PLEASE PRINT This information becomes part of your confidential medical recordPatient History

Purpose

Surgeon/City

Presenting Problem: Please describe the specific problems or questions you would like to have addressed

Name:__________________________________________________ Date of Birth:_________________________

Medical History (Please mark any conditions you've been diagnosed with in the past) Glaucoma Diverticulitis Seizure / Epilepsy Atrial Fibrillation/Arrhythmia Cataracts Hepatitis Anemia Heart Attack Macular degeneration Reflux / GERD / Ulcers Blood clots Coronary Artery Disease Hearing loss Hiatal hernia Arthritis Congestive heart failure High blood pressure Kidney stones Psoriasis Pacemaker High cholesterol Diabetes Eczema Asthma Angina Thyroid disease Depression COPD / Emphysema HIV/AIDS Stroke Fibromyalgia Tuberculosis

Gout Pulmonary embolus

Cancer: Type:______________________________________________________________________________________________________

Other:

For children less than 5 years old: Birth Weight__________ Complications Breech

Review of Systems (Please complete the following by checking Yes or No)

General YES NO Cardiovascular YES NO Musculoskeletal YES NOFever Chest pain Muscle painChills Palpitations Neck painWeight loss Shortness of breath laying down Back painMalaise/Fatigue Pain in limbs Joint painSweating Leg swelling FallsWeakness Shortness of breath at night

Endo/Heme/Aller YES NOSkin YES NO Respiratory YES NO Easy bruise/bleedRash Cough Environmental allergiesItching Coughing up blood Excessive thirst

Sputum productionHENT YES NO Shortness of breath Neurological YES NOHeadaches Wheezing DizzinessHearing loss TinglingRinging in ears Gastrointestinal YES NO Tremor

Ear Pain Heartburn Loss of feeling

Ear discharge Nausea Speech changeNosebleeds Vomiting Focal weaknessCongestion Abdominal pain SeizuresUpper airway wheezing Diarrhea Loss of consciousnessSore throat Constipation

Blood in stool Psychiatric YES NOEyes YES NO Black stools DepressionBlurred vision Suicidal ideasDouble vision Genitourinary YES NO Substance abuseLight sensitivity Painful urination HallucinationsEye pain Urgency Nervous/AnxiousEye discharge Frequency InsomniaEye redness Blood in urine Memory loss

Flank painOther:

Last Menstrual Period: ____________________ Miscarriages / Abortions #____________

OMP24831 4/23/2019 (Patient History & ROS, OMP) Page 2 of 2

Contraception: Yes No Type:____________ Vaginal Deliveries: #____________ C-Section: #____________

Registration and Update Form (Confidential) Please complete all Required sections of this form then Provide an Insurance Card and Photo ID for copying If you have any questions or concerns, please ask for assistance. We will be happy to help.

.Patient Information.

Last Name: First Name: Middle Name:

Social Security #: Gender: Date of Birth:

Mailing Address: City:

State: Zip:

Phone (Mark the best) Home: Work:

Mobile: Message:

Aliases / Nick Name: E-mail:

.General. Needs Interpreter If yes; Language: Religion:

Marital Status: Married Single Divorced Widowed Legally Separated

Ethnicity: Hispanic American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White/Caucasian Other:

Employer: Employment Status: Part Time Full Time Never Employed Not Employed Active Military Duty Disabled Retired Self Employed Student Full Time Student Part Time

Employer Address: City: State: Zip:

Occupation: Phone

.Primary Care Doctor. (Doctor, Nurse Practitioner, Physicians Assistant, etc.)

Dr. Name: Phone:

.Patient Emergency Contacts-At least 1 immediate family member.

Name: Relationship: Phone:

Name: Relationship: Phone:

.Financially Responsible Party (Guarantor). (Complete if Guarantor is the parent or anyone other than the patient)

Guarantor Name: Relationship to Patient:

Address: City: State: Zip:

Social Security #: Gender: Date of Birth:

Home Phone: Work Phone:

Employer: Employment Status: Part Time Full Time Never Employed Not Employed Active Military Duty Disabled Retired Self Employed Student Full Time Student Part Time

Employer Address: City: State: Zip:

Occupation: Phone:

.Coverage Information.

Primary Insurance: Subscriber ID: Group #:

Subscriber Name: Date of Birth Relationship:

Address: City: State: Zip:

Secondary Insurance: Subscriber ID: Group #:

Subscriber Name: Date of Birth Relationship

Address: City: State Zip:

.Advanced Directives. Do you have any Advanced Directives? Yes No

OMC20866 3‐15 Registration & Update 

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

Olympic Medical Physicians 433 E. 8th St. Port Angeles, WA 98362 (360) 565-7670

Fax: (360) 565-7672

PATIENT INFORMATION

Patient Name (printed): Previous Name(s):

Date of Birth: Daytime Telephone Number:

SEND INFORMATION TO: (please be specific)

Name: Olympic Medical Physicians

Address: 433 E. 8th St.

City: Port Angeles State: WA Zip: 98362

Phone #: (360) 565-7670 Fax #: (360) 565-7672

INFORMATION TO BE RELEASED FROM: (please be specific)

Provider Name/Organization:

Address:

City: State: Zip:

Phone #: Fax #:

PURPOSE OF DISCLOSURE

Transfer of Care Self Specialist Other (must complete)

INFORMATION TO BE DISCLOSED

Medical Records from last two years

Limited Health Information or Documentation Dates of Service:

Complete Medical Chart Contents

Other Expiration Date (or event) FORMAT Paper Electronic (MyChart)

CONSENT TO DISCLOSE

If the patient is unable to sign, please indicate such and the authority to act of the person who is signing for the patient. This form may be revoked at any time, providing the information has not already been disclosed. Please see our Notice of Privacy Practices for instructions as to how to revoke this authorization. We will not condition treatment on the completion of the authorization. Also, please be aware that once we disclose this information per your instructions the information is subject to re-disclosure and may no longer be protected by the HIPAA of 1996.

Date Signature of patient or representative Relationship to patient

DISCLOSURES REQUIRING SPECIAL CONSENT

My signature below specifically authorizes the release of healthcare information relating to the testing, diagnosis, or treatment for (Please initial beside the specific information to disclose):

HIV/AIDS Virus Mental Health/Psychiatric Disorders

Sexually Transmitted Diseases Drug, Alcohol Abuse/Treatment

Date Signature of patient or representative Relationship to patient

FOR FACILITY USE ONLY

Date Received:______________ Date Information Released:______________ Chart #:_________________

Person/Department Sending Records: ______________________________________________________________

Faxed Mailed MyChart Picked Up:_____________________ Other:______________________ OMP32625 2/9/2016 Approved

PERSONAL RELEASE OF PROTECTED HEALTH INFORMATION

PATIENT INFORMATION

Patient Name (printed): Previous Name(s):

Date of Birth: Daytime Telephone Number:

INFORMATION TO BE RELEASED FROM:

I hereby authorize Olympic Medical Physicians Clinics to release the following information contained in my medical record and/or information regarding my medical care or condition as described in detail below.

INFORMATION TO BE RELEASED TO:

Name:

Relationship: Phone Number:

Name:

Relationship: Phone Number:

Name:

Relationship: Phone Number:

GENERAL INFORMATION TO BE RELEASED

You may release test results and appointment information to the above named person(s)

You may discuss my medical condition(s) and/or current treatment with the above named person(s)

DISCLOSURES REQUIRING SPECIAL CONSENT

My signature below specifically authorizes the release of healthcare information relating to the testing, diagnosis, or treatment for (Please initial beside the specific information to disclose):

Drug and Alcohol Abuse/Treatment

Mental Health/Psychiatric Disorders

HIV/AIDS Virus

Sexually Transmitted Infections

Reproductive Health

CONSENT TO DISCLOSE

By my signature below I indicate that I understand that I have the right to revoke this authorization in writing at any time. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. This consent is specific to verbal disclosures only. If release of records is being requested an Authorization to Disclose Protected Health Information will need to be obtained.

This authorization will be valid until:

Date Signature of patient or representative Relationship to patient

FOR FACILITY USE ONLY

Date Received: Date Information Released: Chart #:

Person/Department Sending Records:

Faxed Mailed Picked Up: Other: OMP25178 12/18/2019

Financial Assistance Plain Language Summary

Do I qualify? Based on your income and family size, you may qualify for a discount of 30-100% of your bill. In some cases, we’ll evaluate criteria other than income. For example, if you experience a catastrophic event, you may qualify regardless of income.

Examples: Individual with

$18,000 income = 60% discount

Couple with $48,000 income = 30% discount

Family of four with $24,000 income = 100% discount

For a full list of family incomes, family sizes, and discounts, see the next page.

What does the Program cover? The Program covers medically necessary care provided by us or by one of our providers. How do I apply? Consult a Patient Financial Service Representative at 360-417-7111 for help applying. For a free copy of the entire Financial Assistance Policy and an application:

Online: www.olympicmedical.org then go to Patients & Visitors, Billing & Financial Services

In Person: Visit the Patient Financial Services Department at 519 S Peabody, Port Angeles, WA 98362 Office hours are Monday-Friday 8:00 AM to 4:30 PM

Mail: Mail a request to Olympic Medical Center, 519 S Peabody, Port Angeles, WA 98362

Telephone: Call Patient Financial Services at (360) 417-7111 or (800) 854-2844

Mail or bring your completed application and required documentation to Olympic Medical Center, 519 S Peabody St., Port Angeles, WA 98362. We process submitted applications only once they are complete. If your application is not complete, we will notify you and provide an opportunity to send the missing documentation or information.

Olympic Medical Center complies with applicable Federal civil rights laws and

does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Spanish

Español

Olympic Medical Center cumple con las leyes federales de derechos civiles aplicables

y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 1-360-417-7000 TTY: 1-360-417-8686

Chinese

繁體中文

Olympic Medical Center 遵守適用的聯邦民權法律規定，

不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電

1-360-417-7000 TTY: 1-360-417-8686

FI32565 1/29/2020 (Flyer)

Financial Assistance Sliding Scale 2020

Gross Monthly Income

Family Size

100% Discount

(100% FPG)

80% Discount

(125% FPG)

60% Discount

(150% FPG)

45% Discount

(200% FPG)

30% Discount

(300% FPG)

1

0 - 1,063

1,064 - 1,329

1,330 - 1,595

1,596 - 2,126

2,127 - 3,189 2

0 - 1,437

1,438 - 1,796

1,797 - 2,156

2,157 - 2,874

2,875 - 4,311

3

0 - 1,810

1,811 - 2,263

2,264 - 2,715

2,716 - 3,620

3,621 - 5,430 4

0 - 2,183

2,184 - 2,729

2,730 - 3,275

3,276 - 4,366

4,367 - 6,549

5

0 - 2,557

2,558 - 3,196

3,197 - 3,836

3,837 - 5,114

5,115 - 7,671 6

0 - 2,930

2,931 - 3,663

3,664 - 4,395

4,396 - 5,860

5,861 - 8,790

7

0 - 3,303

3,304 - 4,129

4,130 - 4,955

4,956 - 6,606

6,607 - 9,909 8

0 - 3,677

3,678 - 4,596

4,597 - 5,516

5,517 - 7,354

7,355 - 11,031

Based on Annual Gross Income

Family Size

100% Discount

(100% FPG)

80% Discount

(125% FPG)

60% Discount

(150% FPG)

45% Discount

(200% FPG)

30% Discount

(300% FPG)

1

0 - 12,760

12,761 - 15,950

15,951 - 19,140

19,141 - 25,520

25,521 - 38,280 2

0 - 17,240

17,241 - 21,550

21,551 - 25,860

25,861 - 34,480

34,481 - 51,720

3

0 - 21,720

21,721 - 27,150

27,151 - 32,580

32,581 - 43,440

43,441 - 65,160 4

0 - 26,200

26,201 - 32,750

32,751 - 39,300

39,301 - 52,400

52,401 - 78,600

5

0 - 30,680

30,681 - 38,350

38,351 - 46,020

46,021 - 61,360

61,361 - 92,040 6

0 - 35,160

35,161 - 43,950

43,951 - 52,740

52,741 - 70,320

70,321 - 105,480

7

0 - 39,640

39,641 - 49,550

49,551 - 59,460

59,461 - 79,280

79,281 - 118,920 8

0 - 44,120

44,121 - 55,150

55,151 - 66,180

66,181 - 88,240

88,241 - 132,360

Due to yearly updates to this information, there may be a more recent version.

The latest version will be posted on our website:

www.olympicmedical.org then go to Patients & Visitors, Billing & Financial Services