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Dear Kaniksu Patient, Welcome to Kaniksu Health Services (KHS), a Community Health Center that provides quality and affordable medical, pediatric, dental, behavioral health and veteran care, regardless of a patient s ability to pay. For your convenience, we have locations in: Bonners Ferry Ponderay Priest River Sandpoint VA Sandpoint Pediatrics Our goal is to help you and the people you love stay healthy or return to good health. Since our first family health center opened in 2002, Kaniksu Health Services has provided our patients with timely, affordable and quality care; because to us, you are not just people in a waiting room. You are part of our family. This letter is intended to guide you through a few facts and steps to make your relationship with KHS as healthy as possible. Your first step as a patient with KHS is to select a primary care physician (PCP) Regularly visiting a primary care provider (PCP) is useful for good health and wellness. Research shows that patients with a PCP better manage chronic diseases, can lower their overall health care costs, and are more satisfied with their care. Your Kaniksu PCP will work with a healthcare team to coordinate your care all in one place so that you have the ability to access a wide variety of health services, including preventive care. We understand that from time to time it is necessary to see specialists outside of Kaniksu. When you do, make sure you alert the specialist/ hospital that you are a patient of KHS and the name of your PCP to ensure excellent care transitions. One of the first questions we are often asked is What is a CHC? A community health center (CHC) is a non-profit provider of quality and affordable care. To ensure income is not a barrier to care, patients may receive a discount on their healthcare services, according to their income. The Kankisu Patient-Centered Medical Home (PCMH) A PCMH is not a building or place, but a team of Kaniksu health professionals working together to coordinate care to help you become as healthy as possible. Led by your primary care provider, your Kaniksu PCMH team will: Care for you as a whole & provide you with better, more personalized care Ensure awareness of prevention and wellness measures such as immunizations, smoking cessation, cancer screenings or reducing obesity Guide you through the complex healthcare system and track ALL your healthcare reports and medications Provide coordinated care of chronic conditions such as asthma, diabetes, heart disease, arthritis, depression, hypertension and others Offer you better access to care through longer hours, more services A Few Things You May Not Expect Clinical Pharmacist - Kaniksu Health Services has a clinical pharmacist on staff who works as part of your healthcare team to review medications, make recommendations to help with the management of chronic diseases, and certify each medication is appropriate and achieving desired outcomes. Medical, Dental, Behavioral Health, Pediatrics: 6615 Comanche Street, Bonners Ferry, ID 80805, (208) 263-7101 Medical, Dental, Behavioral Health, Pediatrics: 30410 Hwy 200, Ponderay, ID 83852, (208) 263-7101 Medical, Behavioral Health, Pediatrics: 6509 Hwy 2, Priest River, ID 83865, (208) 263-7101 Pediatrics, Behavioral Health: 420 N. 2nd Ave, Sandpoint, ID 83864, (208) 265-2242 VA Clinic: 420 N. 2nd Ave, Sandpoint, ID 83864, (208) 263-0450 Administrative Offices: 301 Cedar St #206, P.O. Box 2160, Sandpoint, ID 83864, (208) 263-7101 www.kaniksuhealthservices.org

Medication Assistance - We offer our patients better access to prescriptions at discounted prices at many Bonner and Boundary county pharmacies. Only patients of Kaniksu Health Services are eligible for the discounts, which can be anywhere from 25 to 50% off. Ask your provider for a list of participating pharmacies. Additionally, some patients may be eligible for FREE medications. Ask to speak to our Medication Assistance Specialist to see if you qualify. Dental & Behavioral Health Services Our dental team offers full care for Idaho Smiles (Medicaid) patients. This includes: pregnant women, children 19 years of age and under, and eligible special needs adults. Emergency services are available for residents of Boundary and Bonner Counties. For those meeting income guidelines a sliding scale applies. We believe that truly meaningful health care addresses all aspects of a person, including behavioral and emotional needs. As a key component of our integrated, patient-centered model our behavioral health team works alongside your medical team to deliver services utilizing a varied team of professionals. Insurance - There are many new opportunities to get coverage with health and dental insurance, either through Medicaid, Medicare or through the insurance marketplace. If you have any questions about the Affordable Care Act, Medicare or Medicaid, or need assistance enrolling in the Health Insurance Marketplace, contact us at (208) 263-7101 and our Outreach & Enrollment Specialist will be happy to help you. Patient Portal - The patient portal allows convenient 24-hour access to personal health information from anywhere with an Internet connection. Using a secure username and password, patients can: See Benefits & Insurance Coverage Update Contact Information Securely Message Your Care Team Review Lab Results & Immunizations View and Request Appointments and Prescription Renewals When to visit the Emergency Room - Before you find yourself sitting for hours in a hospital emergency room, or end up with medical fees that are not fully covered by your health plan, here are some things you should know before you or a family member need immediate medical care. You should first try to contact your Kaniksu PCP. We are available by phone 24/7 for assistance. (208) 263-7101 for general questions, or (208) 265-2242 for pediatrics. Still not sure? Here are a few guidelines for determining if you should go to the ER: Excessive bleeding that won t stop When breathing is very hard or you have chest pain with shortness of breath/sweating/pain that spreads to your jaw, arms or neck. Antacids will not help with a heart attack! After a serious accident Community Resources - Navigating the health care system and accessing available resources can be challenging. Our Patient Assistance Specialist will help connect you with the services you need more FREE of charge. Care Management For eligible patients, a Care Manager acts as a personal health coach who will get to know you and your needs in depth and discover ways to help you successfully achieve a more healthy life style. If you would like assistance and access to additional resources that will aid you in self-managing a chronic condition, ask how a Care Manager may be assigned to you. Sincerely, Your KHS Care Team

Kaniksu Health Services KHS Bonners Ferry Clinic: 6615 Comanche Street - Bonners Ferry, ID 83805 208-267-1718 KHS Sandpoint Clinic: 30410 Highway 200 Ponderay, ID 83852 208-263-7101 KHS Sandpoint Pediatric Clinic: 420 N Second Ave Sandpoint ID 83864 208-265-2242 KHS Priest River Clinic: 6509 Hwy 2 Suite 101, Priest River, ID 83856 208-448-2321 Patient: Last name First name Middle M / F Date of Birth Age SS# Home Ph. # Alternate Ph. # E-mail Address: Preferred Method of Contact Mailing Address City State Zip Employment Year-round Seasonal Self Employed Retired Unemployed Disabled Student Are you or any member of your family a migrant or agricultural worker Yes No Veteran Yes No Homeless Yes No Do you have insurance? Yes No (Please give cards to receptionist for copying) Insurance Carrier Name: Policy Holder Name: Patient Primary Doctor: How did you hear about us? Friend/relative Website Parent / Guardian / Spouse / Emergency Contact Social Media Newspaper Magazine Other: Single / Married / Widowed Last Name First Name Middle M / F Relationship to patient Home Ph. # Date of Birth: Please circle Size of Family Unit and the Total Household Income on the chart below: 1 $12,140 $12,141 to $16,389 $16,390 to $18,210 $18,211 to $24,159 $24,160 2 $16,460 $16,461 to $22,221 $22,222 to $24,690 $24,691 to $32,755 $32,756 3 $20,780 $20,781 to $28,053 $28,054 to $31,170 $31,171 to $41,352 $41,353 4 $25,100 $25,101 to $33,885 $33,886 to $37,650 $37,651 to $49,949 $49,950 5 $29,420 $29,421 to $39,717 $39,718 to $44,130 $44,131 to $58,546 $58,547 6 $33,740 $33,741 to $45,549 $45,550 to $50,610 $50,611 to $67,143 $67,144 7 $38,060 $38,061 to $51,381 $51,382 to $57,090 $57,091 to $75,739 $75,740 8 $42,380 $42,381 to $57,213 $57,214 to $63,570 $63,571 to $84,336 $84,337 9 $46,700 $46,701 to $63,045 $63,046 to $70,050 $70,051 to $92,933 $92,934 If household size and income exceeds what is on this chart please fill in Annual income $ I hereby agree that the above information is true and correct to the best of my knowledge. Signature of Patient/Guardian Date ****Sliding Fee Waiver of Participation**** I decline participation in the Sliding Fee Discount Program and I understand that I am responsible for the entire bill or any portion that remains after insurance payments. Signature of Patient/Guardian Date Race White (Not Hispanic or Latino) African American (Not Hispanic or Latino) Native American Native Alaskan Pacific Islander Asian Native Hawaiian Other Ethnicity Hispanic/ Latino Non-Hispanic/ Latino Unknown Primary language spoken in household English Spanish Other I hereby authorize Kaniksu Health Services to request on my behalf, and to collect directly, all public and private insurance coverage benefits due for products and services supplied. In the event that insurance benefits are paid directly to me, I will endorse to KHS all checks for such payments. I also authorize release of any information concerning my (or my child s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I hereby agree that I am financially responsible for all charges incurred for the services provided. Signature Parent/Guardian (if minor) Date: KHS Form FB01-a Confidential Financial Information Jan 2018

Kaniksu Health Services Consent to Share Confidential Medical/Dental Information To be valid, this form must be filled out COMPLETELY, including what information you are giving us permission to share. Patient s Legal Name: Date Of Birth: I HEREBY AUTHORIZE KANIKSU HEALTH SERVICES TO SHARE THE FOLLOWING INFORMATION: My general medical/dental information. My lab results (note: checking this box does NOT mean we will share results of STD or HIV/AIDS test) My appointment times, dates and reasons for the visits The medications I am taking The following information (specify) Sensitive health information including (please check all that apply to consent): Sexually transmitted disease (STD) testing and treatment HIV/AIDS testing and treatment * Mental health diagnoses and treatment Pregnancy testing and prenatal care * Drug and alcohol use history and treatment Birth control/family planning * WITH THE FOLLOWING PEOPLE: Full Name: Relationship: Full Name: Relationship: Full Name: Relationship: I understand that I may cancel this consent at any time (by writing to Kaniksu Health Services Medical Records), but that cancelling it will not affect any information that has already been released. This authorization will automatically expire in one year from the date signed unless I choose to cancel it, in writing prior to expiration. Signature: Date: Relationship to minor patient (if parent or legal guardian)* If you are not the minor patient s parent, you must give us proof of guardianship (for example, a court order or power of attorney) *A minor patient s signature is required for us to share information about care for: (1) conditions relating to the minor s sexuality including, but not limited to: family planning and sexually transmitted diseases (age 14 and above); (2) alcoholism and/or drug abuse (age 13 and above); and (3) mental health conditions (age 13 and above).

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