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Patient Guide

Welcome to the MultiCare Patient Guide. We’ve bundled some of the most important information our patients need into one place.


Acknowledgment of Conditions for Treatment & Financial Disclosures

The undersigned Patient and/or Patient’s Representative hereby acknowledges receipt of MultiCare Health System’s Handout entitled “Notice of Privacy Practices, Conditions for Treatment, Financial Disclosures, Patient’s Right Materials, Financial Assistance,” Version 87-9158-0D (Rev. 3/20), referenced here as the Handout.

CONSENT FOR CARE: I agree to care and treatment by MultiCare Health System (“MultiCare”) and the physicians, surgeons and other licensed independent practitioners involved in my care, together with other health care professionals employed by or otherwise affiliated with MultiCare who are designated to provide care for me. This consent may include examinations, tests, imaging studies, labs, anesthesia, and medical or surgical treatment(s). Additional documents and consent forms may be required for specific procedures. I understand I have the right to ask questions about my care at any time, and to be involved in my care decisions.

RISKS OF TREATMENT: NO GUARANTEE OF RESULTS OR CURE: No promise or guarantee of results or cure has been made to me. I know there are risks related to surgical, medical, or diagnostic procedure(s). These risks include the potential for infection, blood clots in veins and lungs, bleeding, allergic reactions, and death.

PHOTOGRAPHS FOR TREATMENT, DIAGNOSIS AND/OR IDENTIFICATION: For diagnosis and treatment purposes, I allow images such as photographs to be taken and used. This includes video and electronic monitoring or recording methods. These images may be used to add to written information about my illness or injury. Some images are used once and immediately discarded when no longer needed. Others may be kept as part of my medical record, at the option of my treatment providers. Photographs of me may also be taken for identification purposes.

IMAGES OR RECORDINGS OF HEALTH CARE PROVIDERS: I understand I must obtain the permission of all health care provider(s) and any other individuals present before I can take photographs or video of any members of my care team. I also understand I cannot record conversations by any means without first obtaining the permission of all persons being recorded.

NON-EMPLOYED PHYSICIANS & PROVIDERS: I understand there are physicians or other licensed providers who practice at MultiCare who are not employed by MultiCare. These individuals are independent providers and are not employees or agents of MultiCare. These include anesthesiologists, radiologists, pathologists, neonatologists, and PICU physicians. It also includes MultiCare Allenmore, Good Samaritan, Covington, Auburn Medical Center, Deaconess, Valley, and Tacoma General emergency department physicians and providers. I understand these providers use their own independent judgment in their medical care and treatment. MultiCare does not control the medical care and treatment given by these providers. I understand that MultiCare has provided me with a list of all independent providers or groups who provide care to me, together with their contact information within this handout (Understanding Your Bill section). I understand that I may receive separate bills for services provided by those parties.

FINANCIAL AGREEMENT: I agree to pay MultiCare for care at its regular rates and terms applicable to my care and any applicable health insurance coverage I have. I permit MultiCare to appeal any denial received from my insurance company. If a third party payor will not pay, I agree to pay for the services given, subject to any applicable contractual or governmental regulations. If a third party caused my injuries, I understand that MultiCare may file a medical services lien as permitted under RCW 60.44.010. (This lien attaches only to a portion of the proceeds of any settlement between me and the party that caused me harm.) If my bill is sent to a lawyer or collection agency, I will pay all reasonable attorneys’ fees and costs, together with interest and any amounts otherwise found to be owing. Information about the estimated charges for health services is available upon request. I understand I have the right to request this information.

AGENTS & CONTRACTORS: Whenever MultiCare is referenced above, it is my intent to include its employees, officers, agents, attorneys, first and third party liability and claims agents, third-party claims administrators and collection agencies, as well as their agents or employees, to receive any information that MultiCare would otherwise be entitled to receive.

MEDICARE: MultiCare’s insurance and patient billing processes are consistent with the requirements established by CMS. If I am a Medicare participant, I understand that I need to pay for services that are not covered by the Medicare Program. This may include, but is not limited to, cosmetic surgery, dental care, take-home and “over the counter” medications, private duty nurses, services not medically needed, personal items, services covered by car or liability insurance, or where a third party is otherwise responsible for any accident or injury leading to my need for care, as well as any services not otherwise covered by Medicare. If I remain in the hospital at any time after it has been determined that Medicare -covered services are no longer medically necessary, I understand that I will be personally responsible for paying for such services after I am decertified as a Medicare-covered patient.

CO-INSURANCE: There may be a co-insurance for care given related to my Medicare or other insurance benefits. I know I will need to pay a higher co-insurance for services provided by a hospital-based clinic or department. If these services were given in a non-hospital based setting, my co-insurance would be lower.

ASSIGNMENT OF BENEFITS; PERMISSION TO ALLOW MULTICARE TO DETERMINE, APPLY AND OBTAIN BENEFITS, INFORMATION AND PAYMENT: I permit payment from insurance or other third-party payors to go to MultiCare directly. I permit MultiCare, in MultiCare’s sole judgment, to determine, apply for and obtain benefits, and get paid from, any and/or all available payor sources until my bill is paid in full. I understand and agree that, to the extent necessary to receive payment or reimbursement for services provided at MultiCare, I authorize MultiCare to, access any applicable accident reports, industrial injury (workers compensation) reports and/or police, fire or other first responder reports or investigations related to my treatment or injury, as well as any records of any claims, lawsuits, insurance claims or investigations that pertain to my medical care and treatment, or the circumstances leading to same, together with any applicable consumer and/or credit reports pertaining to me. I further authorize any applicable Federal, State or Local government or administrative agency to fully and completely release any and all of my records and/or incident information they have about me, pertaining to my care or the circumstances leading to my need for care, upon request by MultiCare.

PHONE, EMAIL, TEXT MESSAGING AUTHORIZATIONS: I grant permission and consent to MultiCare: (1) to contact me by phone at any phone number associated with me, including wireless (cell) numbers; (2) to leave answering machine and voicemail messages for me, and include in any such messages information required by law (including debt collection laws) and/or regarding amounts owed by me; (3) to send me text messages or emails using any email or cellular device addresses I provide and; (4) to use pre-recorded/artificial voice messages and/or and automatic dialing device (an “autodialer”)in connection with any communications made to me or related to my scheduled services and my account, unless I have exercised an “opt out” option associated with such emails or text messages or have otherwise notified MultiCare in writing to discontinue such communications using those pathways. I understand that opt out processes may take up to ten (10) business days to go into effect. Unless you have opted out, relevant communications may continue after the expiration of this consent form. I understand that I am not required to accept messages in these formats as a condition of receiving services at MultiCare.

EMAIL CONTAINING PROTECTED HEALTH INFORMATION; MYCHART: I understand that exchanging email, text or other written communications with my health care provider(s) or other members of my care team can result in protected health information being disclosed to unauthorized persons, and that MultiCare cannot control who views such information when sent in unencrypted form. I understand that MultiCare offers “MyChart” to all patients, which provides a fully encrypted and protected pathway for communicating with most of its provid- ers, although not all MultiCare providers choose to utilize MyChart. If I initiate or respond to communications using unencrypted pathways, I assume the risk that my information may be compromised, and I authorize MultiCare and its providers to communicate with me using that process, unless or until I choose to opt out of such communications pathways by notifying MultiCare in writing, allowing up to ten business days to implement any change in my communications pathways.

ADVANCE DIRECTIVES / LIVING WILL / POLST FORMS: I understand that I have the right to carry out an Advance Directive for Health Care (Often referenced as a “Living Will.”). I understand I can get information on the Advance Directive policy at www.multicare.org/important-policies. I understand that POLST form (Physician’s Orders for Life Sustaining Treatment) may not always serve as a substitute for an Advance Directive. If I have completed a POLST or Advance Directive form, I agree to provide a copy of such form(s) to MultiCare. I also understand that I can complete a separate Advance Directive for Mental Health.

HEALTH CARE POWER OF ATTORNEY / MENTAL HEALTH POWER OF ATTORNEY: I understand I can nominate another person or persons to make health care decisions for me at times when I am unable to do so. These can include routine health care decisions (including life and death decisions) as well as mental health decisions. Examples of these can be found at https://www.multicare.org/for-patients/. If I complete either of these forms, I will provide MultiCare with copies, or otherwise tell MultiCare where they are located.

If requested, I understand that the Handout is available in English, Russian, Spanish and Vietnamese.


CONDITIONS FOR TREATMENT – CONSENT FOR CARE – FINANCIAL DISCLOSURES & PATIENT’S RIGHTS MATERIALS

MULTICARE: I understand that MultiCare operates numerous hospitals, inpatient and outpatient clinics, urgent care centers and emergency departments, including free-standing emergency departments, along with many laboratory and imaging sites. For a complete list of all MultiCare locations, see www.multicare.org. I understand that portions of my care may be rendered at more than one site or location, even when I do not move between facilities.

RELEASE OF INFORMATION: MultiCare may use and disclose my information for the purposes of continuity of care, payment for health care services, and for its own health care operations, and when required to do so by Federal and state law. Federal and state law may place limitations on the use and disclosure of my health information, particularly if it pertains to drug or alcohol treatment, mental health treatment, and diagnosis or treatment of sexually transmitted diseases.

PAYMENT INFORMATION: To receive payment for care, MultiCare may need to disclose protected health information such as my name, address, date of birth, admission/discharge date(s), telephone numbers, social security number, medical records, account numbers, insurance information and charges at MultiCare, along with the circumstances leading to my need for treatment. This information may be shared with applicable sources of payment for the health care services provided to me. See MultiCare’s Notice of Privacy Practices for more detail: https://www.multicare.org/patient-privacy/

HEALTH CARE WORKER EXPOSURE / BLOOD TESTING: I agree that if any health care worker (including police, fire or other first responder) is exposed to my blood or other body fluids, MultiCare may test my blood, tissue or other body fluid for communicable disease, such as hepatitis, HIV or syphilis, or other communicable diseases. I understand that any test result received because of such exposure may not appear in my medical record unless I am separately treated for any positive test results at a MultiCare facility. My test results may be shared with the exposed worker and/or their health care provider(s). I understand that a positive HIV or Hepatitis C Antibody test must be reported to the local Health Department. I understand that I may be contacted by MultiCare or others if my test is positive.

SUPPLEMENTAL INFORMATION: I acknowledge that I have been provided and/or offered the following brochures or information, and I understand that additional copies are available upon request in hard copy and/or on the MultiCare website. www.multicare.org Many of MultiCare’s forms are also translated into other languages, and I will ask if a translated version of any form is needed:

Patient Rights & Responsibilities: This brochure has important information about my rights and responsibilities as a patient. It includes MultiCare’s procedures to resolve complaints.

Notice of Privacy Practices: This describes your privacy rights and how MultiCare may use and share my personal health information, and how its participation in various Organized Health Care Arrangements and/or Clinically Integrated Networks or other Accountable Care Organizations may impact the use of my protected health information.

Financial Assistance: MultiCare offers Financial Assistance based on an individual’s ability to pay for medically necessary health care services.

To learn more about Financial Assistance options, visit www.multicare.org or call 800-919-1936.

Other: I may also be provided with other brochures or documents pertaining to my specific health conditions, now or at a later time. These may include communications that relate to my gender, age and generalized health condition, or that may relate to specific diagnoses, as well as general or specific information about programs or services offered by, or in conjunction with, MultiCare.

Victims of Crime: If you were the victim of a crime, resources may be available through Crime Victims Compensation Program (CVCP) to assist with the many costs associated with violent crime. For more information on medical treatment and counseling services, contact the CVCP at 800-762-3716 or visit www.CrimeVictims.Lni.wa.gov.

ESL / Translation Services: If English is a second language for you, and/or you otherwise need the assistance of a translator, please let us know and services will be provided.

DISCRIMINATION: MultiCare does not discriminate against any person on the basis of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or any other basis prohibited by state or federal law in care and treatment or participation in its programs, services, activities or employment. If you are concerned about discrimination at MultiCare, please call us at:

STUDENT CARE PROVIDERS: Under supervision of my health care team, I understand that medical residents, medical students, nursing students or other trainees may take part in my care and treatment.

VALUABLES: If I retain any valuables, such as wedding rings, jewelry, wrist watches, dentures, eyeglasses, hearing aids or other personal effects, instead of sending them home or placing them in safekeeping with MultiCare, MultiCare shall not be responsible for loss or damage to any personal property kept by me. I acknowledge that MultiCare recommends that I do not bring or keep valuables with me during my time at MultiCare facilities.

DISPOSAL OF REMOVED TISSUE: I allow my physician or surgeon, and/or MultiCare, to decide whether to retain or dispose of any tissue removed during any examination, treatment or procedure(s).

PATIENT SATISFACTION SURVEYS: I agree that MultiCare may contact me after my care or treatment to ask about my experience as a patient. I understand that MultiCare uses an independent agency to do this survey. I know I am not required to respond to the survey, and my participation (or not) in any survey will not impact any care that I receive.

DISRUPTIVE BEHAVIOR: I understand that MultiCare has a “zero tolerance” policy for disruptive behavior, which includes any behavior that makes it difficult for the care team to provide services. This policy protects all patients, families, visitors and MultiCare employees and providers. I agree to report any disruptive behavior to my health care team and I will take all steps that I reasonably can to avoid participating in any disruptive behavior myself, or through any friends or family members. Individuals engaged in disruptive behavior may be precluded from calling, visiting or otherwise participating in my care.

SURROGATE DECISION-MAKERS: If I am unable to sign this acknowledgment myself, I understand that my statutory surrogate decision-maker(s) will sign this acknowledgment for me, unless my consent for treatment is otherwise implied under Washington law (i.e. due to a medical emergency.) If this acknowledgment is signed by a surrogate, it shall have the same force and effect as if signed by me directly, at a time and under circumstances when I would otherwise have been deemed to be competent. I understand the importance of telling my potential surrogate decision-makers of my wishes through the use of health care advance directive forms or others means, as my health conditions change over time.


Patient Rights and Responsibilities

PATIENT RIGHTS BY LAW
You have the right to:

  • be treated and cared for with dignity and respect;
  • be free from any forms of restraint or seclusion used as a means of convenience, discipline, coercion or retaliation; and to have the least restrictive method of restraint or seclusion used only when necessary to ensure patient safety
  • confidentiality, privacy, security, complaint resolution, spiritual care, and communication. If communication restrictions are necessary for patient care and safety, we will document and explain the restrictions to you and your family;
  • be protected from abuse and neglect; and
    • ~ Have access to protective services;
  • complain about your care and treatment without fear of retribution or denial of care;
  • timely complaint resolution;
  • be involved in all aspects of your care including:
    • ~ Refusing care and treatment; and
    • ~ Resolving problems with care decisions;
  • information of unanticipated outcomes that will be provided to you or your family or any surrogate decision makers you have identified;
  • be informed and agree to your care;
  • family input in care decisions;
  • have advance directives and for the hospital to respect and follow those directives;
  • request no resuscitation or life-sustaining treatment;
  • end of life care;
  • donate organs and other tissues with:
    • ~ Medical staff input; and
    • ~ Direction by family or surrogate decision makers;
  • be free from restraints and seclusion of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff;
  • a written statement of these patient rights.

MULTICARE HAS ADOPTED AND IMPLEMENTED POLICIES AND PROCEDURES:

  • to identify patients who are potential organ and tissue donors
  • to address research, investigation, and clinical trials including:
    • ~ How to authorize research if you choose to participate;
    • ~ Require staff to follow informed consent laws; and
    • ~ Not hindering your access to care if you refuse to participate in a researchstudy.
  • to inform each patient (or support person, where appropriate)
    • ~ of his or her visitation right, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights;
    • ~ of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex spouse or domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.
  • to not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.
  • to ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences.

ADDITIONAL PATIENT RIGHTS AND ETHICS

You have the right to:

  • an interpreter, free of charge.
  • know about your condition and to be told about the results of care, including unexpected ones.
  • effective communication that provides information in a manner you understand, that meets your needs in the vent of vision, speech, hearing or cognitive impairment.
  • to pain management.
  • understand the choices for treatment including alternatives (including no treatment), risks and benefits.
  • obtain a second opinion.
  • know the name and role of each person giving you care.
  • know about your medications, any equipment used, and community resources you might need.
  • choose whether or not you would like to participate in medical research studies. You should have complete information about the study and sign a consent if you choose to participate. If you choose not to participate, your medical care will not be negatively affected.
  • have your bill explained to you.
  • obtain copies of your medical records. You may do so by contacting the MultiCare Health Information Management Department (medical records) at:

CONCERNS, COMPLAINTS, GRIEVANCES

If you have a concern regarding care or service provided at any MultiCare location, we want to talk with you. You may file this complaint without fear of retribution or denial of care by:

  • Notifying any staff member of your concern during your visit or stay
  • Speaking with a manager directly about your concern

For MultiCare Puget Sound Region

  • Please call: 253-403-1739
  • Email us at: [email protected]
  • Write us at: MultiCare Health System, MS: 315-3C-CE • PO Box 5299, Tacoma, WA 98415-0299

For MultiCare Deaconess Hospital:

  • Please call: 509-473-3223
  • Email us at: [email protected]
  • Write us at: MultiCare Deaconess Hospital, Attention: Patient & Family Relations, 800 W. 5th Ave., Spokane, WA 99204

For MultiCare Valley Hospital:

  • Please call: 509-473-5853
  • Email us at [email protected]
  • Write us at: MultiCare Valley Hospital, Attention: Patient & Family Relations, 12606 E Mission Ave., Spokane Valley, WA 99216

For MultiCare Rockwood Clinic:

When we receive your concern, we will send it to the appropriate leadership for review.

If we are unable to immediately resolve your issue:

  • we will provide written notice that a formal complaint has been opened within 7 business days.
  • we will provide a written closure letter within 30 business days.

The letter will contain:

  • the basic steps taken to review your concerns
  • results of review
  • actions taken to resolve the issue

If we are unable to provide closure within 30 business days, written notice will be provided every 30 business days until we are able to review and resolve your concerns.

The letter will contain:

  • the basic steps taken to review your concerns
  • results of review
  • actions taken to resolve the issue

For Privacy, Compliance or Discrimination concerns please call 866-264-6121

YOU HAVE THE RIGHT TO FILE A COMPLAINT WITH THE WASHINGTON STATE DEPARTMENT OF HEALTH AT 800-633-6828 OR BY WRITING WA DOH, HEALTH SYSTEMS QUALITY ASSURANCE, COMPLAINT INTAKE, P.O. BOX 47857, OLYMPIA WA 98504.

  • The complaint system for the state is available online at [email protected] or you may contact one of the following:

Or you may contact one of the following:

  • Adult Protective Services ................................................................. 877-734-6277
  • Child Protective Services ................................................................ 800-422-7517
  • Consumer Protection Agency ......................................................... 800-551-4636
  • Health Facilities and Services Licensing ........................................ 800-633-6828
  • Medicaid Fraud Control Unit........................................................... 360-586-8888
  • State Attorney General................................................................... 360-753-6200
  • The Joint Commission ...............................jointcommission.org or 800-994-6610

In addition, you may contact Kepro at 888-305-6759 or 855-843-4776 (TTY) for quality of care issues, insurance coverage decisions, or to appeal a premature discharge.

Patient Responsibilities

  • Let someone know if you don’t understand what you are being told.
  • Tell us everything you know about your health.
  • Let someone know if there are changes in your condition.
  • Participate in making decisions, following directions and accepting responsibility for your choices.
  • Respect the rights and privacy of others.
  • If you are unable to keep an appointment, let us know as soon as possible.
  • Deal with your bill promptly and let the billing department know if you need to make special payment arrangements.
  • Refer to Patient Advocacy if you need more information or help.

Patients are also responsible for the following MultiCare Health System rules and regulations affecting patient care and conduct

  • Patients may not smoke any substance (tobacco, marijuana, or vaporized nicotine devices) or use any form of tobacco products on MultiCare campuses.
  • Patients may not disturb other patients.
  • Patients or family members may not interfere with care provided to other patients and the operations of MultiCare Health System.
  • Patients may not conduct any illegal activities on the premises of MultiCare Health System.
  • Patients are responsible for providing accurate personal identification information.
  • Patients are responsible for being considerate of the rights of other patients and MultiCare Health System staff.
  • Patients are responsible for informing their medical team if they have special needs.
  • Patients are responsible for being respectful of the property of other persons and MultiCare Health System.
  • Patients are responsible for letting their medical team know if they have complaints or concerns. Please report any complaints or concerns to a member of your healthcare team, who will then contact the appropriate staff. Complaints and concerns may also be reported to Patient Advocacy.

Special Rights of Adolescents

In addition to the patient rights stated above, the law provides the following rights for adolescent patients:

  • A minor patient 13 years or older may consent to outpatient treatment for mental health and substance abuse issues (drugs and alcohol).
  • A minor patient 14 years or older may consent to outpatient treatment for sexually transmitted diseases.
  • A minor patient, regardless of age, may consent to birth control or pregnancy-related care.
  • Emancipated minors may consent for their own treatment.
  • If you wish to be seen for diagnosis/treatment for one of the above conditions, tell the appointment scheduler when you make your appointment and to your provider.

Understanding Your Bill

Healthcare billing is complicated. Although everyone is charged the same, different insurance plans may mean that patients are responsible for paying different amounts for the same service. This is why it’s critical to give the right personal and insurance information to your healthcare provider. If you get follow up questions from either your insurance plan or your health care provider, please respond as quickly as possible.

QUESTIONS AND CONCERNS ABOUT YOUR HOSPITAL BILL

Please contact us for help with:

  • ✓ Applying for free or other reduced price care
  • ✓ Applying for Medicaid or other public insurance programs
  • ✓ Understanding your bill
  • ✓ To discuss options for setting up a payment plan
  • ✓ Visit www.multicare.org/billing/ to pay your bill online

MultiCare toll free 800-919-1936

HOSPITAL BASED CLINICS

A number of our clinics and other facilities where you receive care are classified as hospital-based clinics. Patients may incur additional out-of-pocket expenses at a hospital-based clinic, because a clinical service at a hospital-based clinic may be billed as an outpatient hospital service — in addition to the bill for the professional service (ie, the bill from your doctor).

MultiCare has taken steps to help patients know if they are getting care in a hospital-based clinic, by displaying a poster in any location designated as a hospital-based clinic. You may also call the clinic before your visit to find out if they are a hospital-based clinic.

Know your rights under the Balance Billing Protection Act

Beginning January 1, 2020, Washington state law protects you from ‘surprise billing’ or ‘balance billing’ if you receive emergency care or are treated at an in-network hospital or outpatient surgical facility

What is ‘surprise billing’ or ‘balance billing’ and when does it happen?

Under your health plan, you’re responsible for certain cost-sharing amounts. This includes copayments, coinsurance and deductibles. You may have additional costs or be responsible for the entire bill if you see a provider or go to a facility that is not in your plan’s provider network.

Some providers and facilities have not signed a contract with your insurer. They are called ‘out-of-network’ providers or facilities. They can bill you the difference between what your insurer pays and the amount the provider or facility bills. This is called ‘surprise billing’ or ‘balance billing.’

Insurers are required to tell you, via their websites or on request, which providers, hospitals and facilities are in their networks. And hospitals, surgical facilities and providers must tell you which provider networks they participate in on their website or on request.

When you CANNOT be balance billed:

Emergency Services

The most you can be billed for emergency services is your plan’s in-network cost-sharing amount even if you receive services at an out-of-network hospital in Washington, Oregon or Idaho or from an out-of-network provider that works at the hospital. The provider and facility cannot balance bill you for emergency services.

Certain services at an In-Network Hospital or Outpatient Surgical Facility

When you receive surgery, anesthesia, pathology, radiology, laboratory, or hospitalist services from an out-of-network provider while you are at an in-network hospital or outpatient surgical facility, the most you can be billed is your in-network cost-sharing amount. These providers cannot balance bill you.

In situations when balance billing is not allowed, the following protections also apply:

  • Your insurer will pay out-of-network providers and facilities directly. You are only responsible for paying your in-network cost-sharing.
  • Your insurer must:
    • ~ Base you rcost-sharing responsibility on what it would pay an in-network provider or facility in your area and show that amount in your explanation of benefits.
    • ~ Count any amount you pay for emergency services or certain out-of-network services (described above) toward your deductible and out-of-pocket limit.
  • Your provider, hospital, or facility must refund any amount you overpay within 30 business days.
  • A provider, hospital, or outpatient surgical facility cannot ask you to limit or give up these rights.

If you receive services from an out-of-network provider, hospital or facility in any OTHER situation, you may still be balance billed, or you may be responsible for the entire bill.

This law does not apply to all health plans. If you get your health insurance from your employer, the law might not protect you. Be sure to check your plan documents or contact your insurer for more information.

If you believe you’ve been wrongly billed, file a complaint with the Washington state Office of the Insurance Commissioner at www.insurance.wa.gov or call 800-562-6900.

QUESTIONS ABOUT BILLS FROM OTHER PROVIDERS

During your stay you may receive services from physicians or other health care professionals with whom MultiCare has contracted to provide services. You should check with your health plan to make sure you are in-network for both the facility and the providers who may be listed below. If you receive a bill from any of these groups and have questions about that bill, you may contact them at the telephone numbers listed or MultiCare at 800-919-1936.

EMERGENCY PHYSICIANS

Good Samaritan
Mt. Rainier Emergency Physicians, 855-571-2845

Good Samaritan - Obstetrics
OB Hospitalist Group, 888-442-8454

Good Samaritan – Off Campus Emergency Department
Western Washington Emergency Physicians, 833-471-9787

Auburn
Cascade Emergency Physicians, 800-225-0953

Tacoma General, Allenmore, Covington
Tacoma Emergency Care Physicians, 855-736-2699
Trauma Trust, 800-919-1936

Deaconess, Valley
Spokane Emergency Care Physicians, 855-736-2699

IMAGING/RADIOLOGY READS

Tacoma General, Mary Bridge, Good Samaritan, Allenmore & Covington
TRA Medical Imaging, 866-231-9211

Auburn
Vantage Radiology, 253-661-1700
Washington Nuclear Medicine LLC, 206-963-5339

Deaconess,Valley
Radia, 888-927-8023

AMBULANCES

Auburn, Tacoma General, Mary Bridge, Good Samaritan, Allenmore & Covington
Falck, 844-231-8264
Rural Metro, 877-571-2544

Deaconess,Valley
AMR, 800-228-7601

ANESTHESIA GROUP

Good Samaritan, Auburn, Covington
Rainier Anesthesia Associates, 800-693-3396

Allenmore, Tacoma General, Mary Bridge, Gig Harbor
Tacoma Anesthesia Associates, 253-274-1642

Deaconess,Valley
Anesthesia Associates, 888-900-3788

HOSPITALIST TEAM

Auburn, Tacoma General, Allenmore, Good Samaritan & Covington
Sound Physicians, 844-801-3821

Deaconess & Valley
Rockwood Hospitalist, 509-342-3600

OTHER MULTICARE PHYSICIANS

Auburn, Tacoma General, Mary Bridge, Good Samaritan, Allenmore & Covington
MultiCare Medical Associates, 800-919-1936

PATHOLOGIST

Auburn, Tacoma General, Mary Bridge, Good Samaritan, Allenmore & Covington
Western Washington Pathology, 855-974-6126

Deaconess,Valley
Cellnetix, 877-340-5884

PEDIATRIC INTENSIVE CARE

Auburn, Tacoma General, Mary Bridge, Good Samaritan, Valley
Pediatrix Medical Group, 855-315-4058

DURABLE MEDICAL EQUIPMENT

Auburn
Breg (DME), 800-254-0072

VIRTUAL CARE CUSTOMER SUPPORT
Video or E-Visit, 253-200-3125


Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. THIS NOTICE ALSO DESCRIBES YOUR RIGHTS AND SOME OBLIGATIONS MULTICARE HAS REGARDING THE USE AND DISCLOSURE OF YOUR HEALTH INFORMATION.

PLEASE REVIEW IT CAREFULLY.

For purposes of this Notice, “MultiCare” or “we” means MultiCare Health System, including MultiCare Connected Care, Cardiac Heart and Vascular Institute, and members of the MultiCare Behavior Health Network: Greater Lakes Mental Healthcare and Navos.

MULTICARE’S PLEDGE AND RESPONSIBILITIES REGARDING YOUR PROTECTED HEALTH INFORMATION

We understand that information about you and your medical and behavioral health is personal. We are committed to protecting health information about you and are required under federal and state law to take steps to protect this information. Under federal privacy laws, this information is called “protected health information”. Protected healthcare information includes certain information we have created or received that identifies you, including information regarding your health or payment for your health at a MultiCare facility, whether by hospital personnel, your personal doctor or other practitioners involved in your health care. It includes your medical records and personal information such as your name, social security number, address, and phone number.

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this Notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

WHO WILL FOLLOW THIS NOTICE

This Notice describes the practices of MultiCare and that of:

  • Any health care professional authorized to enter information into your medical record at any MultiCare facility.
  • All departments and units of MultiCare.
  • Any member of a volunteer group we allow to help you while you are at a MultiCare facility.
  • All MultiCare employees and personnel including contracted or agency staff.
  • MultiCare Connected Care workforce members.
  • Other health care providers who have agreed to follow and abide by the “joint notice of privacy practices” terms described below.

JOINT NOTICE OF PRIVACY PRACTICES

In addition to those persons identified above, a number of other independent practitioners have agreed with MultiCare to follow this Notice as a joint privacy practices notice in accordance with federal privacy laws related to care delivered at MultiCare facilities, including the members of the medical staffs of Tacoma General Hospital, Allenmore Hospital, Mary Bridge Children’s Hospital, Good Samaritan Hospital, Auburn Medical Center, MultiCare Deaconess Hospital, MultiCare Covington Medical Center, MultiCare Valley Hospital, and other independent providers or organizations delivering care at MultiCare facilities.
The independent practitioners that have agreed to follow this Notice may access your health information where there is a legitimate need to do so for treatment, payment and health care operations purposes related to the joint care setting at MultiCare facilities. The independent practitioners that have agreed to follow this joint notice likely will have separate Notice of Privacy Practices for care delivered at non-MultiCare facilities (e.g. a physician’s office). You are encouraged to request information from a non-MultiCare practitioner about any separate Notice of Privacy Practices followed by that practitioner at non-MultiCare offices or facilities.

MULTICARE CONNECTED CARE NETWORK

MultiCare is part of the MultiCare Connected Care Network which is an organized healthcare arrangement (OHCA). AnOHCA is (i) a clinically integrated setting in which individuals typically receive healthcare from more than one healthcare provider or (ii) an organized system of healthcare in which more than one health care provider participates. The healthcare providers who participate in the OHCA will share health and billing information about you with one another as may be necessary to carry out treatment, payment, and healthcare operations activities.

OTHERS WHO MAY ACCESS OR USE YOUR HEALTH INFORMATION

MultiCare participates in health information exchange networks to facilitate the secure exchange of your electronic health information regarding your treatment between and among other health care providers or health care entities including but not limited to Emergency Department Information Exchange (EDIE), Virtual Lifetime Electronic Record (VLER - DoD/VA), or CareEverywhere (Organizations with Epic). MultiCare also provides connectivity to its Electronic Health Record to independent community health care providers. As a condition of such access, each of these providers agrees to using information on a “need to know” basis and to comply with state and federal laws related to privacy and security.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Unless indicated otherwise, you may exercise one of your privacy rights by submitting a written request to MultiCare Health System, Health Information Management, PO Box 5299, MS: 315-C3-HIM, Tacoma, WA 98415-0299. For more specific instructions on what information to include in a written request, contact Health Information Management by phone 253-403-2423.

YOU HAVE A RIGHT TO:
Get an electronic or paper copy of your health record – Usually this includes treatment and billing records and does not include psychotherapy notes.

  • To request an opportunity to inspect and/or copy your protected health information in either paper or electronic format, visit www.multicare.org to obtain a copy of the authorization request (release of information) form or contact Health Information Management (medical records) at 253-403-2423. Greater Lakes and Navos medical records may also be requested via fax at 253-697-8393 or through [email protected].
  • You may be charged a fee for copying, mailing or other supplies associated with your request.
  • In certain limited circumstances, we may deny your request to inspect and/or copy your protected health information. You may request that the denial be reviewed.

Ask us to correct certain protected health information – If you feel that information we have about you is incorrect or incomplete you can request an amendment to such information.

  • We may say “no” to your request, but we’ll tell you why in writing.

Request an accounting of certain disclosures – You may request an accounting of certain disclosures of your protected health information listing all the disclosures we made to others.

  • This list will not include disclosures made for the purposes of treatment, payment, and health care operations identified previously.
  • The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Request restrictions – You may request in writing that we limit the way we use and disclose your protected health information.

  • You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend.
  • If you want to put such a restriction in place, please notify your healthcare provider’s front office staff and complete the Request for Restrictions form prior to being seen.
  • We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If we do agree to your request, we will comply unless the information is needed to provide emergency treatment to you.

Right to request nondisclosure to health plans for self-paid items or services – You have a right to request in writing that healthcare items or services for which you self-pay for in full in advance of your visit not be disclosed to your health plan.

  • We will say “yes” unless a law requires us to share that information.
  • You are responsible for notifying any other providers, such as your pharmacy, of any restriction requests.

Request confidential communications – You may request in writing that confidential communications about medical or behavioral health matters be made in a certain way or at a certain location.

  • For example, you can ask that we only contact you at work or by mail to an alternative address.
  • We will say yes to all reasonable requests. You do not have to provide a reason, but the request must specify how or where you wish to be contacted.

Choose someone to act for you – If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

  • We will ask the person to show proof of this authority toact for you before we take any action.

Receive a paper copy of this notice – You can request a copy of this Notice at any time from any MultiCare employee.

USES AND DISCLOSURE OF YOUR HEALTH INFORMATION BY MULTICARE

Your Choices: For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we will not share your information unless you give us written permission (signed consent):

  • Marketing purposes where remuneration is received
    • ~ Limited information about you may be used to support communication about available products or services.
    • ~ If you do not wish to receive such materials, please call 855-884-4284 or email [email protected].
  • Sale of your information
  • Most sharing of psychotherapy notes
  • Situations not described in this Notice that do not pose a threat to health or safety

In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

  • If you no longer wish to receive fundraising requests supporting MultiCare, please call (toll-free) 855-884-4284855-884-4284
  • , or alternatively send an e-mail to [email protected]
  • We respect your choice regarding fundraising communications and your decision will have no impact on your treatment or payment for services at MultiCare.

MultiCare typically will use your information in the following ways:

Treatment: We may use and disclose your protected health information to provide you with medical treatment and services and share it with other professionals who treat you.

  • This use and disclosure may be for continuity of care or to doctors, nurses, technicians, health care students, or other health system personnel who are involved in your care.
  • We may use and disclose your health information to different departments to coordinate activities such as prescriptions, lab work and x-rays and to other health care providers who may be involved in your medical care, such as long-term care facilities, other hospitals or clinics, or remote health care providers such as the services offered by telemedicine providers who may reside in other communities, including communities outside of Washington and Idaho.

Payment: As permitted by law, we may use or disclose your health information to get payment from health plans and other entities.

  • This includes billing for treatment and services you receive at a MultiCare facility.
  • In addition, we may use or disclose your information to collect payment or to obtain prior approval for treatment and services.

Health system operations: We can use and share your health information to run our business, improve your care, and contact you when necessary.

  • Running our business includes activities such as scheduling, infection control, administering the health plan, and population health activities.
  • We may also use and disclose your information to other individuals (such as consultants and attorneys) and organizations that help us with our business activities.
  • We may also use your health information for internal purposes, like ensuring the quality of care, identifying training needs, reviewing outcomes, sending patient satisfaction surveys, and other administrative activities.
  • We may also disclose your information to Business Associates, or companies that provide a service to us or on our behalf and have provided satisfactory assurances that they will protect your health information.

MultiCare may also use your information in the following ways:

Public Health and Safety – We may disclose your health information to agencies when necessary, to support public health activities. These activities generally include the following:

  • To prevent or control disease, injury or disability;
  • To report births and deaths;
  • To report abuse or neglect;
  • To report reactions to medications or problems with products;
  • To notify people of recalls 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 when required or authorized by law.

Research – We can use or share your information for health research.

Limited Data Set Information – We may disclose limited health information to third parties for purposes of research, public health and health care operations. This limited data set will not include any information that could be used to identify you directly.

Comply with the Law – We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Organ and Tissue Donation – We can share health information about you with organ procurement organizations.
Coroners, Medical Examiners, and Funeral Directors – We can share health information with a coroner, medical examiner, or funeral director when a person dies.

Workers’ Compensation – We can use or share health information about you for workers’ compensation claims.

Government Requests and Law Enforcement – We can use or share health information about you:

  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and Presidential protective services
  • In limited circumstances, for law enforcement purposes or with a law enforcement official

Lawsuits and Disputes – We may disclose your health information in response to a court or administrative order, subpoena, discovery request, or other lawful process, if you are involved in a lawsuit or a dispute.

Contacting You – We may use and disclose health information to reach you about appointments and other matters. We may contact you by mail, telephone, or email.

  • For example, we may leave voice messages at the telephone number you provide us with, and we may respond to your email address.

Treatment Alternatives – We may use or disclose information to tell you about or recommend possible treatment options or alternatives.

Health-Related Benefits and Services – We may use or disclose information to tell you about health-related benefits, services, or medical education classes.

Inmates – We may disclose your health information to a correctional facility or law enforcement official, if you are an inmate or in custody.

Incidental Disclosures – Certain incidental disclosures of your health information may occur as a byproduct of lawful and permitted use and disclosure of your health information. Reasonable safeguards are in place to minimize these disclosures.

Blood Conservation Services – We may use or disclose your health information if you have indicated affiliations with certain organizations and we believe you may be an ideal candidate who could benefit from blood conservation services.

Serious and imminent threats – We may share your information when needed to lessen a serious and imminent threat to the health or safety of you, the public, or another person.

SPECIAL INFORMATION TYPES

Washington, Idaho and federal law provide additional confidentiality protections in some circumstances. MultiCare generally may not release without specific authorization the following patient information:

  • Washington — Specific sexually transmitted diseases
  • State and federal law — Substance Use Disorder records that may be specially protected
  • Washington — Behavioral health records that are specially protected in some circumstances

OTHER USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

Other uses and disclosures of your protected health information not covered by our current Notice or applicable laws will only be made with your written permission. You may revoke any permission by submitting a request in writing to the MultiCare Privacy Office (at the contact information under Questions and Complaints). If you revoke your permission, we will no longer use or disclose your protected health information for the reasons covered by your written authorization unless required by law. You understand that we are unable to take back any uses or disclosures we have already made, while your permission was in effect, and that we are required to retain our records of the care that we provide to you.

CHANGES TO THIS NOTICE

MultiCare can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request, at our facilities, and on our web site.

QUESTIONS AND COMPLAINTS

If you have general questions about this Notice, please contact the MultiCare Privacy Office by phone: 866-264-6121 or email: [email protected].

If you believe your privacy rights have been violated, you may file a complaint with the MultiCare Privacy Office, MultiCare, P.O. Box 5299, MS: 737-2-CCIA, Tacoma, WA 98415-0299. If we cannot resolve your concerns, you also have the right to file a written complaint with the Secretary of the Department of Health and Human Services (HHS), Office for Civil Rights. We will not retaliate against you for filing a complaint and the quality of your care will not be jeopardized.


Financial Assistance at MultiCare

MultiCare Health System is committed to serving all patients, including those who lack health insurance coverage and who cannot pay for all or part of the essential care they receive. We are committed to treating all patients with compassion. We are committed to maintaining Financial Assistance policies that are consistent with our mission and values and that take into account an individual’s ability to pay for medically necessary health care services. Patients qualifying for Financial Assistance will not be charged more than the amounts generally billed for emergency or other medically necessary care. To learn more about how our Financial Assistance Team may help you with our Financial Assistance Programs please visit www.multicare. org/financial-assistance or call 800-919-1936.

FINANCIAL ASSISTANCE POLICIES
Financial Assistance policies, plain language summaries, and application materials are available to you online or by mail. Translated copies are available. Please visit www.multicare.org/financial-assistance. Please call 800-919-1936 if you’d like to receive these materials by mail.

The following information summarizes our FINANCIAL ASSISTANCE PROGRAMS

Patients may apply for Financial Assistance by submitting a Financial Assistance application with income information. MultiCare uses the Federal Poverty Guidelines to help determine what Financial Assistance Program best fits your needs.

INCOME IS UP TO 300% OF FEDERAL POVERTY GUIDELINES

After a financial assessment of the patient’s income has been completed, the patient’s bill will be reduced by 100% if their income level is at or below 300% of the Federal Poverty Guidelines.

INCOME IS 301 – 500% OF FEDERAL POVERTY GUIDELINES

After a financial assessment of the patient’s income and assets have been completed, the patient’s bill will be reduced if their income level is between 301% and 500% of the Federal Poverty Guidelines.

2020 Federal Poverty Guideline

Income Levels:

Family Size Gross Annual Income 300% 350% 400% 450% 500%
1 $12,760 $38,280 $44,660 $51,040 $57,420 $63,800
2 $17,240 $51,720 $60,340 $68,960 $77,580 $86,200
3 $21,720 $65,160 $76,020 $86,880 $97,740 $108,600
4 $26,200 $78,600 $91,700 $104,800 $117,900 $131,000
5 $30,680 $92,040 $107,380 $122,720 $138,060 $153,400
6 $35,160 $105,480 $123,060 $140,640 $158,220 $175,800
7 $39,640 $118,920 $138,740 $158,560 $178,380 $198,200
8 $44,120 $132,360 $154,420 $176,480 $198,540 $220,600
9 $48,600 $145,800 $170,100 $194,400 $218,700 $243,000
10 $53,080 $159,240 $185,780 $212,320 $238,860 $265,400
Each Additional $4,480

MultiCare Health System Discount

Poverty Level, Up To 300% 350% 400% 450% 500%
Charity Discount 100% 95% 90% 80% 70%
Patient Responsibility 0% 5% 10% 20% 30%