This online form will take you about 5-10 minutes to complete and will expedite your check-in process. If you prefer to complete the forms in our office, please arrive early for your appointment. All questions marked with a * are required.
CONFIDENTIALITY, DISCLAIMER AND LIMITATIONS OF SERVICE
Pregnancy Resource Centers of Central Oregon (PRCCO) is a Christian non-profit organization offering pregnancy test services, limited OB ultrasound exams (up to 20 weeks) and other services. All of our services, information and resources are free.
Confidentiality: All information is kept confidential with a few exceptions. Oregon law and/or our concern for your safety requires that we report knowledge of a Client who is a danger to themselves or others, is abusing a minor or is a minor being abused, is a victim of rape, or a runaway.
Consultations: Our Client Advocates are trained volunteers and are not licensed or degreed personnel. Any consultation you receive is not intended as a substitute for professional counseling.
Pregnancy Testing: Your pregnancy test is 97-99% accurate; however you should seek to confirm the results of your test with a licensed physician. This applies to both nurse and self-administered tests. Whether the test is positive or negative, you should consult with a licensed physician. We do not provide prenatal care.
Ultrasound: The limited OB ultrasound is a medical service and is provided by a licensed Registered Nurse (RN) or Registered Diagnostic Medical Sonographer (RDMS) under the oversight of a local licensed Medical Director.
Abortion: This Center does not offer or refer for pregnancy termination services.
Adoption: We are not a licensed adoption agency and we are not affiliated with any adoption agencies. We offer information about adoption and can provide a list of several adoption agencies for review. Our endorsement of any adoption agency does not warranty their services nor do we receive any financial remuneration from any agency. We do not represent prospective adoptive parents nor assist them in their search for a child. If you decide to consult with an adoption agency, that agency is independent of PRCCO.
Referrals: Although we give referrals for medical care, professional counseling, housing, and other community services, we assume no legal responsibility for services provided by other agencies or individuals; nor are the views of these organizations or individuals necessarily the views of PRCCO.
Fees: All of our services are free of charge. We do not accept any form of payment or collect any insurance information.
Recording Devices: We do not give permission for our staff to be recorded and ask that no recording devices be used while inside this Center. We ask that you turn off your cell phone and all recording devices while inside this Center.
By signing this form (electronically) I am agreeing to hold Pregnancy Resource Centers of Central Oregon harmless from and against all claims or causes of action arising out of a referral by Pregnancy Resource Centers of Central Oregon. I have read and understand the above and hereby authorize the staff of this Center to discuss and render available services as necessary for my care.
Notice of Center Privacy Practices
This notice describes how medical or personal information about you given to this center may be disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY. This center is a medical care provider that does not engage in any transactions covered under the federal Health Insurance Portability and Accountability Act (HIPAA). This center abides by all applicable medical privacy and licensing laws of the State of Oregon. The privacy practices described in this notice are voluntarily undertaken and ARE NOT INTENDED TO CREATE ANY CONTRACTUAL OR LEGAL RIGHTS ON BEHALF OF CLIENTS. We reserve the right to modify our privacy practices and this notice at any time.
1. Safeguarding Your Protected Health Information
Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for health care is considered “Protected Health Information” (PHI). We will extend certain protections to your PHI and to any other personally identifying information which you provide to us, including your SSN, date of birth, home address, telephone number, relationship with this organization, presenting concerns, or services received. This Notice explains how, when, and why we may use or disclose your PHI. Except in specified circumstances, we will only use or disclose the minimum necessary PHI to accomplish the intended purpose of the use or disclosure.
2. How We May Use and Disclose Your Protected Health Information
We use and disclose PHI for a variety of reasons. We may use and/or disclose your PHI internally for purposes of managing your case. For uses beyond that, we will ordinarily obtain your written authorization. The following offers more description and some examples of the potential uses and disclosures of your PHI:
Uses and Disclosures Relating to Health Care and Operations. We restrict access to your PHI to health care personnel who are involved in providing you with care, to other personnel who are involved in providing care and services to you, and to external vendors or subcontractors who perform services ancillary to your care. We maintain physical, electronic, and procedural safeguards restrict access to your PHI. Also, we may use and/or disclose your PHI as may be reasonably necessary in the course of operating this health care facility, including to assess quality and improve services. We may also send or communicate appointment reminders, treatment options, or test results through service providers, subject to our normal confidentiality policies and any special instructions that you have given.
Uses and Disclosures for Which Special Authorization Will Be Sought. For uses beyond operational purposes, we will ordinarily seek to obtain your authorization before disclosing your PHI. However, disclosure of your PHI may be made without your consent or authorization when required by law, when necessary to avert a threat of harm to you or a third person, or when other circumstances may require or reasonably warrant such disclosure.
3. How You May Have Access to Your Protected Health Information.
The following is a description of the steps you may take to access or to otherwise control disposition of your PHI:
To request restrictions on uses/disclosures: You may ask that we limit how we use or disclose your PHI. We will consider your request, but we are not legally bound to agree to the restriction. To the extent that we do agree to such restrictions, we will abide by such restrictions except in emergency situations. We cannot agree to limit uses/disclosures that are required by law. Pregnancy Resource Centers of Central Oregon and its personnel hold a religious and/or moral objection to abortion. Therefore, in accordance with our constitutionally protected Right of Conscience, we do not send PHI directly to abortion providers, even upon request
To choose how we contact you: You may ask that we send you information at an alternative address or by alternative means. We will agree to your request so long as it is reasonably easy for us to do so.
To inspect and copy your PHI: You will be permitted to inspect your PHI and/or obtain a copy upon written request. We will respond to your request within 10 business days. A reasonable fee for copies in excess of 10 pages may be charged.
To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request in writing that we correct or add to the record. We will respond within 60 days of receiving your request. Any denial will state the reasons for the denial. If we approve the request for amendment, we will change the PHI and so inform you.
To find out what disclosures have been made: You may request for us to provide you with a list of all disclosures of your PHI which we have made (except for such disclosures as have been made in connection with services you have received, your treatment, or our health care operations, or as specifically required by law). We will respond to your request within 10 business days of receiving it.
To receive this notice: You may receive a paper or electronic copy of this notice upon request.
4. If your PHI security is compromised
If PHI is acquired, used or disclosed in a manner that is not permitted under this notice or that compromises the security or privacy of that PHI, (referred to as a “breach”), we will provide appropriate notice of such breach without unreasonable delay and in no case later than 10 business days after the discovery of the compromise. We may delegate this responsibility to a subcontractor. However, you will be responsible to take any additional steps you deem necessary to protect your identity and security.
5. Contacting the Privacy Information Officer
To request any information or submit any request regarding your PHI described in #3 above, or to express concerns about our privacy practices if you believe your privacy has been compromised, please contact: Pregnancy Resource Centers of Central Oregon 369 NE Revere Ave., #102 Bend, OR 97701
Virtual Meeting Request
I request to participate in virtual meetings/consultations with Pregnancy Resource Centers of Central Oregon (PRCCO) personnel. I understand that virtual meetings/consultations are provided as a convenience to me and at my request. I further understand that I can withdraw my consent verbally or in writing for this type of meeting at any time and center personnel will make reasonable efforts to provide appointment availability during the business hours of PRCCO, if permitted based on my state’s pandemic response. I also understand that PRCCO may discontinue providing virtual consultations to me if they are unable to meet my needs this way.
I understand that PRCCO only offers virtual meetings/consultations to clients residing in the state of Oregon and that I am responsible to notify center personnel if I move out of this state.
I understand that my consultation will be with center personnel, which may include a client/patient advocate, and/or with a licensed professional. I also understand that consultations with unlicensed personnel are not a substitute for therapy and/or healthcare or for the advice of other licensed professionals.
I understand that the platform used by the center to provide me with virtual consultations takes reasonable precautions to protect my privacy; however, virtual meetings/consultations come with certain risks, including interruptions, the possibility of unauthorized access to the personal information I submit online, and technical difficulties. I further understand that these and other risks can happen with online communication and will not hold PRCCO liable for any breach of confidentiality resulting from the digital platform used for the meeting.