It is our privilege to serve you. In the spirit of building a great relationship with you, here is what you can expect from us, and what we expect from you in return:

YOU HAVE A RIGHT TO:

• Considerate and respectful treatment, without discrimination.
• Privacy and personal dignity.
• Know the names of the Mountain Family staff caring for you.
• Receive information about and consent to care recommended by your primary care provider.
• Tell your health care providers in advance about the care you do or do not want to receive, and to have your wishes respected.
• Refuse any/all treatment and to be informed of the medical or other consequences of your actions.
• Confidentiality of all information in your medical record, except as otherwise provided by law or third party payment contract, and as outlined in the Health Insurance Portability Assurance Act (HIPAA).
• Feel safe and free from harassment or discrimination.
• Pain assessment and management.
• Review your bill.
• Review your medical record with your primary care provider and receive a copy of your medical record upon request.
• Take part in decisions involving your health care.
• Change your primary care provider if other qualified providers are available.
• Express your concerns, complaints or grievances.
• Be provided with appropriate education or training about your health and health care needs.
• Seek a second opinion and obtain a referral to a specialist when your needs are outside our scope of services.

YOU HAVE A RESPONSIBILITY TO:

• Provide a complete and accurate medical history, including medications and drugs you have used, previous illnesses, injuries or medical care you have received, and your current health status.
• Ask questions when you do not understand.
• Follow your provider’s instructions once you have agreed to the recommended care.
• Accept the consequences of your actions if you choose not to follow your provider’s recommendations, which may include discharging you from the practice if your refusal prevents us from providing care according to ethical and professional standards.
• Take care of your financial obligations to Mountain Family.
• Be aware of the rights of other patients and Mountain Family staff, and respect Mountain Family property.
• Keep scheduled appointments and be on time for those appointments.
• Actively participate in decisions concerning your health care.

This describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. 

YOUR MEDICAL RECORDS AND YOUR RIGHTS

ACCESS

Only you or your personal representative have the right to access your medical record without your written permission. If you would like to have your medical record released, or grant permission for Mountain Family staff to hold verbal conversations with another individual or health care provider, please complete an Authorization to Release Private Health Information form and submit it to the Health Records Management Department with a photo ID. There are several ways you can turn in the completed form: drop off the completed form at any Mountain Family location, fax to 970-945-1055, mail to PO Box 339, Glenwood Springs, CO 81602, or email to elprice@qhndirect.org. (Please click here for an authorization form in Spanish.)

Mountain Family is able to release your medical information without your permission to your health insurance company for billing and payment purposes. We are also able to release your medical records to another health care provider we have referred you to, or in emergency situations for treatment purposes. For other exceptions, please refer to our Notice of Privacy Practices (and here in Spanish).

PAYMENT

Mountain Family is not able to withhold your medical records from you due to non-payment of services rendered. However, we do have the right to charge you a reasonable amount for the reproduction of your medical records.

CORRECTIONS

You have the right to request a correction or amendment to your medical record if you feel that there is a mistake. You must submit any changes in writing to: Elaena Price, Mountain Family Health Centers, PO Box 339, Glenwood Springs, CO 81602. You can also fax your changes in writing to 970-945-1055, or email elprice@qhndirect.org. Your health care provider and team will review and notify you if the amendment is approved. Your health care provider has the right to deny your request.

For more information, please contact:

• Art Fernandez, Chief Operations Officer
• Elaena Price, Patient Services Manager

PHONE 970-945-2840
FAX 970-945-1055

HIPAA Privacy Statements:

Notice of Privacy Practices (English)
Notice of Privacy Practices (Spanish)

Please mail your completed complaint, compliment or suggestion form to the address below, fax to 970-945-1055, or email to elprice@qhndirect.org.

Mountain Family Health Centers
Attention: Elaena Price
PO Box 339
Glenwood Springs, CO 81602

Please tell us how to contact you so that we can respond. You will not be penalized for filing a complaint.