HIPAA

Patient Name *

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I give A Primary Care Clinic for Adults "APCCFA" my consent to use or disclose my Protected Health Information "PHI" in order to carry out my treatment, obtain payment from my health insurance for servicers, obtain prior-authorizations for imaging and/or prescriptions, to refer me to another provider & for health care operations, like quality reviews. *

I have been informed that I may review and/or receive a copy of APCCFA's Notice of Privacy Practices, for a more complete description of uses and disclosures, before signing this consent. *

A copy of our Privacy Practices is available on our website.

I understand that APCCFA has the right to change their privacy practices and that I may view or receive a copy of any updates. *

I understand that I have the right to request a restriction of how my PHI is used. *

I understand that if APCCFA agrees to my requested restrictions they MUST comply. However, I also understand that APCCFA is NOT required to agree to said request. *

I understand that I may revoke this consent at any time by submitting a written request to APCCFA. *

I also understand that revoking my consent WILL NOT apply to my PHI that has already been used or disclosed. *

By completing the electronic signature field below I acknowledge that I have reviewed and/or received a copy of APCCFA's Privacy Practices.

Electronic signature *

Date *

Influenza and Covid-19 Vaccines

We currently have Flu Shots in stock. However, we do not have Covid-19 vaccines in stock. This message will be updated if we receive more.

If you would like to set up an appointment for a flu shot please email the office.

All Vaccines are for established patients only. We apologize for any inconvenience.

New office location in Shoreline!

We are now in the Rose Crossing Plaza Building at 20011 Ballinger Way NE Suite 202, Shoreline, WA 98155

Face Mask Requirements

Regardless of vaccination status, all persons entering the clinic are still required to wear a face mask. This is necessary to protect us as well as other patients.

Please bring your own face covering with you to your appointment. You will be required to wear your mask correctly at all times while in the office.

We have updated our Late Cancel/No Show policy.

Any appointment cancelled without 12 hours notice and any appointment that is missed will now incur a $100.00 No Show Fee or your care may be terminated. This fee must be paid prior to scheduling another appointment. No exceptions will be made.