OHSU Family Medicine is committed to providing unrestricted access by nsr11162


									        OHSU Family Medicine is committed to providing unrestricted access to personal health care
for everyone. This includes adults and children without health insurance. In order to do this, we are
changing our access policy by offering a membership program for people who do not have insurance.
        Our new program is called Access Assured. If you are not covered by insurance, your Access
Assured membership will let you to receive basic health care at our OHSU Family Medicine clinics at
South Waterfront, and at Gabriel Park. With OHSU Family Medicine Access Assured, services within
our clinic will be available to you at a cost based on OHSU’s Financial Assistance Policy. Your
membership also offers additional services that will not require office visits.
        Applying for Access Assured is easy. Ask our staff to assist you with the membership
application, and show you how to connect with OHSU financial assistance screening. With Access
Assured, you will continue to receive a bill for all services provided in our office; but based on your
financial screening, you may receive discounts for these services.
        Your first six months of membership is available for $250. After the first six months, you can
continue with OHSU Family Medicine by maintaining your Access Assured membership.

Access Assured Membership Options:
Membership for six months:      $250.00                                           PLACE LABEL
Membership for twelve months: $350.00                                                  HERE
Access Assured Membership Benefits:
1. Access to your health care team, 24 hours a day, seven days a week.
2. Access to daytime, evening and weekend appointments.
3. Assistance and advice in obtaining appointments with specialists, hospital, and medical testing
4. Internet access to your own electronic health record, including the ability to send electronic
   messages to us, see your lab results, and receive on-line prescription refills.
5. Internet appointment scheduling.
6. Coordination and advice about your preventive care.
7. Access to telephone medical advice.

When you need to see your doctor, the visit fee for Access Assured members will be determined by
OHSU’s Financial Assistance Program. Information about this financial assistance policy is available
at 503-494-8505.
Access Assured membership is for a minimum of six continuous months.
If you become covered by insurance this membership will remain active for the full six months.
No refunds will be made.
Access Assured membership may not be transferred to other patients.
Payments for your Access Assured membership will not be credited toward charges for office visits.

I have read the above information and understand that this is a Membership Fee only and that
any charges incurred will be my responsibility _________________________________

Name: ______________________________________               Date of birth: __________________

Address: __________________________________ Apt#__________

City: ______________________________________ State: ___________ Zip: ___________

Contact Phone: ___________________________ Email: ___________________________

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