Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

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A. Background Information (con’t) -Describes the services provided directly by the clinic’s staff or through arrangement -Provide guidelines for medical management of health problems; and, -Provide for annual review of the policies -Direct Services (must be provided by clinic staff) •Provide diagnostic and therapeutic services that are commonly furnished in a physician’s offi ce •Provide basic laboratory services (6 tests) -Chemical examinations of urine -Hemoglobin or Hematocrit -Blood sugar -Examination of stool specimens for occult blood -Pregnancy test -Primary culturing for transmittal •Provide Emergency Services -First response to common life-threatening injuries and acute illnesses -Has available drugs used commonly in life-saving procedures •Services Provided through Arrangement (may be provided by individuals other than clinic staff) -In-patient hospital care -Specialized physician services -Specialized diagnostic and laboratory services -Interpreter for foreign language if indicated -Interpreter for deaf and devices to assist communication with blind 5. Patient Health Records •Record System Guided by Written Policies and Procedures •Designated Professional Staff Member Responsible for Maintaining Records •Records must include the following information -Identification data -Physicians’ orders -Physical exam fi ndings -Consultative fi ndings -Social data -Diagnostic and laboratory reports -Consent forms -Medical history -Health status assessment -Signatures of the physician or other health care professionals •Protection of Record Information Policies -Maintenance of confi dentiality, safeguards against loss, destruction or unauthorized use -Written policies and procedures govern use and removal and release of information -Written patient consent is required for release 6
B. Rural Health Clinics in Arizona (as of 8/2008) 1) Bouse Medical Clinic Location: 44031 East Pulmosa Road Bouse, AZ 92885 Mailing Address: Same as above Phone: (928) 512-1777 Fax: (928) 849-3460 Year of Certification: Type of Clinic: Provider-Based Hospital Affiliation: La Paz Regional Hospital 2) Community Health Care of Douglas, Inc Location: 2174 West Oak Avenue Douglas, AZ 85607 Mailing Address: Same as above Phone: (520) 805-5880 Fax: (520) 805-4187 Year of Certification: 2007 Type of Clinic: Provider-Based Hospital Affiliation: Southeast Arizona Medical Center 3) Copper Queen Medical Associates- Bisbee Location: 101 Cole Avenue Bisbee, Arizona 85603 Mailing Address: Same as Above Phone: (520) 432-2042 Fax: (520) 432-2098 Year of Certification: 2004 Type of Clinic: Provider-Based Hospital Affiliation: Copper Queen Community Hospital 4) Copper Queen Medical Associates- Douglas Location: 100 East 5th Street Douglas, Arizona 85607 Mailing Address: Same as Above Phone: (520) 364-7659 Fax: (520) 364-8541 Year of Certification: 2004 Type of Clinic: Provider-Based Hospital Affiliation: Copper Queen Community Hospital 5) Greasewood Clinic Location: Off Route 15 Greasewood, AZ Mailing Address: P.O. Box 457 Ganado, AZ 86505 Phone: (928) 654-3208 Fax: (928) 654-3478 Year of Certification: 1999 Type of Clinic: Provider-Based Hospital Affiliation: Sage Memorial Hospital 6) La Paz Medical Services, Quartzsite Location: 150 East Tyson Road Quartzsite, AZ Mailing Address: P.O. Box 4618 Quartzsite, AZ 85359 Phone: (928) 927-8747 Fax: (928) 927-8748 Year of Certification: 2004 Type of Clinic: Provider-Based Hospital Affiliation: La Paz Regional Hospital 7) Palominas Hereford Rural Health Clinic Location: 10524 East Highway 92 Palomias, AZ 85615 Mailing Address: Same as above Phone: (520) 366-0300 Fax: (520) 432-1724 Year of Certification: 2008 Type of Clinic: Provider-Based Hospital Affiliation: Copper Queen Community Hospital 8) Pleasant Valley Community Medical Center Location: 288 Tewkbury Young, AZ 85554 Mailing Address: Same as Above Phone: (928) 462-3435 Fax: (928) 462-6644 Year of Certification: 1995 Type of Clinic: Independent Hospital Affiliation: Cobre Valley Community Hospital 9) Regional Center for Border Health/San Luis Walk-In Clinic Location: 1896 East Babbitt Lane, Suite D San Luis, Arizona 85349 Mailing Address: Same as Above 7
Page 1 and 2: Arizona Rural Health Clinic Designa
Page 3 and 4: Community Environment & Policy 1295
Page 5: A. Background Information (con’t)
Page 9 and 10: C. Number of Rural Health Clinics i
Page 11 and 12: D. Frequently Asked Questions (con
Page 13 and 14: D. Frequently Asked Questions (con
Page 15 and 16: E. Steps to Becoming a Certified Ru
Page 17 and 18: B. Interpretive Guidelines for Rura
Page 29 and 30: D. Preparing for the Certification
Page 37 and 38: 30 Most Common RHC Survey/Certifica
Page 39 and 40: F. RHC Cost Report The Medicare cos
Page 41 and 42: F. RHC Cost Report (con’t) •Wor
Page 43 and 44: F. RHC Cost Report (con’t) 11) Li
Page 45 and 46: G. Important Resources (con’t) -A
Page 47 and 48: Appendix A. Important Contact Infor
Page 49 and 50: Appendix B. Definitions for Rural H
Page 51 and 52: Appendix C. Federal Primary Care HP
Page 53 and 54: Appendix • C. Federal Primary Car
Page 55 and 56: Appendix D. Federal MUAs in Arizona
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Instructions for completing HCI App
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A. PLEASE LIST IN THE SPACE PROVIDE
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MEDICAL FACILITIES LICENSING 150 N.
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ARIZONA DEPARTMENT OF HEALTH SERVIC
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MEDICAL FACILITIES LICENSING 150 N.
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http://www.azdhs.gov/als/forms/otcs
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Appendix F. Certification Forms 1.
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3. Has successfully completed a for
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DEPARTMENT OF HEALTH AND HUMAN SERV
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DEPARTMENT OF HEALTH AND HUMAN SERV
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According to the Paperwork Reductio
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MEDICARE ENROLLMENT APPLICATION INS
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2990 (Cont.) Form CMS 222-92 03-02
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RURAL HEALTH CLINIC SURVEY REPORT F
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NAME CODE YES NO N/A EXPLANATORY ST
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Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

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