Physical Qualification Packet

Arctic PQ Information
Arctic PQ Information- Contents
Page
PQ Information Packet - Contents
1
Letter to Participant
2
PQ Packet Steps
3–5
U.S. Arctic Program Physical Qualification Important Information (Mandatory
6–9
Reading)
5. COVID-19 Vaccine Requirement
10
6. Appendix 1- Exercise Stress Testing (ETT) Criteria
11
7. Appendix 2: Protocol for TB Testing and Treatment
12 – 18
8. Vaccinations and Infectious Disease
19
9. International Physical Qualifications (PQ)
20
10. HIPAA and Polar Programs
21 – 25
11. UCHealth Notice of Privacy Practices
26 – 34
^^^ Pages in the “Arctic PQ Information” DO NOT need to be submitted to CU Polar Medicine in
your packet.
1.
2.
3.
4.

Arctic PQ Packet - Contents
1. PQ Packet Checklist and Packet Order (This form does not need to be included
in the submitted packet)
2. Physical Qualification (PQ) Overview
3. Electronic Health Record- Registration Form
4. Authorization to Request Protected Health Information
5. Request for Individual Access to Records Protected under the Privacy Act
6. Health Information Exchange (HIE) Opt-In/Opt-Out Request
7. Acknowledgement of Receipt of UCHealth Notice of Privacy Practices
8. Consent to Service
9. Medical History Forms
10. Dear Lab Collection Letter
11. Dear Doctor Letter
12. Arctic Physical Examination
13. Dear Dentist Letter (This form does not need to be included in the submitted
packet)
14. Arctic Dental Examination
15. United States Arctic Program Deployment Consent/Authorization Documents
16. USAP Authorization for Treatment of Field-Member/Participant Under 18
Years of Age (Only submit this form with packet if under 18 years of age)

Page
1
2
3
4 – 11
12 – 16
17
18
19
20 – 24
25
26
27 & 28
29
30
31 & 32
33

^^^ The “Arctic PQ Packet” will be submitted to CU Polar Medicine by fax or mail. All forms listed in the
“Arctic PQ Packet - Contents” are REQUIRED for your PQ packet, except those that indicate they are not
necessary for your submission in (red). This is to help cut down on the number of pages that need to be faxed
or mailed.

REVISED: 01/2024

Arctic PQ Information

1

Dear Participant,
You have been identified as needing to physically qualify for an Arctic deployment in the upcoming season.
We wanted to give some hints on how to PQ and to point out major changes in the program.
1) Please email the PFS Deployment Coordinator, Carol Rowe ([email protected]) to start
the process and inform that you will be applying for a PQ evaluation. Carol Rowe will send
CU Polar Medicine a request for a PQ packet to be sent out. You should receive an email
back within two business days from CU Polar Medicine with your initial paperwork.
Additional information can also be found on www.coloradowm.org/arcticpq/.
2) Please schedule your appointments early: You should try to submit your packet within 4
weeks of receipt to avoid the backup that occurs every March through July. Schedule your
physician appointment first as your physician will complete your lab request information.
3) Do not request tests that are not that are not stated as being required in your packet. Your
doctor may suggest other procedures/tests or dental cleanings during the exam. These costs
are typically not covered by the program.
4) The health questions and testing requirements included during the PQ process are
intended to assess your suitability for deployment under the auspices of the National
Science Foundation’s operations in the Arctic Regions. The PQ process is not a
substitute for your own responsibility to manage your health care or your physician’s
judgement in determining your health care needs. All participants are responsible for
their results and following up/reporting results to their physician. In the event of any
abnormal results, it is the participant's responsibility to follow-up with their provider
to evaluate these and receive further management/care.
5) SEND A COMPLETE PACKET-You are responsible for sending in your packet and
should wait until it is complete. The only exceptions are dental X-rays.
6) After you submit a (mailed or faxed) packet, we will send an email acknowledging receipt,
generally within 2 business days. During peak season, it will take us up to 7 days to evaluate
it and either send a PQ notice or request more information. Due to US government
regulations, we are not able to accept scanned or emailed forms.
7) Please don’t use software/phone solutions/FaxZero to try to fax your chart. They just don’t
work well and result in a delay, as we may need to request that you send them again. If you
do not have access to a physical fax machine, please use the mail or an office center near
you (FedEx, UPS etc.)
8) Do not hide medical conditions. Non-disclosure means an automatic NPQ. We work hard
and can generally waive most medical conditions if we know about them. Please be honest
and thorough so we can ensure your health and help you through the process.
9) You must get your flu vaccine for the upcoming Arctic season of your deployment, if you
are deploying prior to April or February, you can get your vaccine. Please try to get the
vaccination at least two weeks prior to deployment. It takes two weeks for your body to
make antibodies.
10) You must complete your COVID vaccination(s) per CDC’s most recent recommendations, at least 14
days prior to deployment.
Sincerely,
The PQ Team

Arctic PQ Information

2

Physical Qualification Packet- Steps
Note to all participants: As a result of the Covid-19 pandemic, we strongly encourage you
to abide by local guidelines when scheduling your appointments. Please make sure your
appointments are consistent with their instructions and not jeopardizing your safety and
health. Appointments are to be scheduled when it is safe to do so and/or measures are
lifted.
Arctic Participant:
You have been identified for deployment to the Arctic and you need to be Physically
Qualified (PQ’ed). Timely and accurate submittal of this packet is critical for a rapid
deployment! Please complete the following steps, in their entirety, and submit this entire
packet for review to CU Polar Medicine. CU Polar Medicine is the medical provider for
the Arctic programs.
The attached file is the Arctic PQ Packet that contains all the forms needed for the PQ
process. YOU ARE RESPONSIBLE for your Arctic PQ Packet and submittal to CU Polar
Medicine. If you don’t understand any part of the process, please contact CU Polar
Medicine at [email protected], phone 802-275-6367, or Fax 303-724-5649.
STEP 1 – Complete/Sign ALL forms in the ‘Arctic PQ Packet’.
PRINT THESE EMAIL INSTRUCTIONS!
Download the ‘Arctic PQ Packet’ and ‘Arctic PQ Information’ to your computer from
your email or the website (www.coloradowm.org/arcticpq/).
Open the downloaded ‘Arctic PQ Packet’ and ‘Arctic PQ Information’ from your download
folder. You can save the PDF packets, but you CANNOT email it to CU Polar Medicine.
PRINT THE ENTIRE PACKETS.
Fill out and complete the ‘Arctic PQ Packet’ (Pages: 2 – 26, 31 – 32).
Incomplete packets will be returned to you, and it will delay your deployment.
Call program manager, Kellie Schiller at 802-275-6367 if you would like to do Medical
History Criteria Review to check what additional testing, procedures, or documentation
you meet criteria for. She will send you an updated PQ packet that is tailored to your
medical history after this phone call that will have all the necessary check-marks for testing
that you need to receive at your appointments.
STEP 2 – Schedule/Visit your Physician
Schedule an appointment with your medical provider.
Take the ‘Arctic PQ Information’ and ‘Arctic PQ Packet’ into your physician appointment.
Have your medical provider read the ‘Dear Doctor’ letter (page 26 of ‘Arctic PQ Packet’).
If you meet criteria for additional work up listed in the ‘Testing’ section that is not
checked, your provider should order these for you. Please indicate with a check mark
on the form if any of these have been obtained.
Have your provider complete the ‘Arctic Physical Examination’ (pages 27 – 28) in the
‘Arctic PQ Packet’.
Participants are responsible for payment of this examination. You will need to contact
your sponsoring organization for reimbursement.
COLLECT ALL RESULTS FROM THE PHYSICAN. Return results with final
the packet (STEP 5).
Arctic PQ Information

3

STEP 3 – Schedule/Complete your Lab Collection
OPTION 1: Schedule a visit to a LabCorp facility (highly recommended/preferred).
Find a LabCorp location (https://www.labcorp.com/wps/portal/findalab) near you and
schedule an appointment.
Take the packet with the “Dear Lab Collection (LabCorp or Physician)” (page 25 of
‘Arctic PQ Packet’) to your LabCorp appointment.
• You need to fast 8 hours before your lab collection.
• LabCorp direct bills and orders labs to CU’s account, so there is no out-of-pocket
cost to the Participant.
Instructions for how LabCorp can order and bill the labs to CU’s account are located at
the top of the ‘Dear Lab Collection’ page.
If you receive your labs at LabCorp, you can sign up for a LabCorp Patient portal, which
allows you to view, download, and print your LabCorp test results. Register for a
LabCorp patient portal here: https://patient.labcorp.com/account/registration/register
OPTION 2 (If there are no LabCorp locations that are accessible near you):
Take ‘Arctic PQ Information’ and ‘Arctic PQ Packet’ to your Physician appointment in
STEP 2.
Have your physician administer the required lab tests listed on the “Dear Lab Collection
(LabCorp or Physician)” (page 25 of ‘Arctic PQ Packet’) and give your results to you. You
will need to include your lab results from your physician in your final packet.
Participants who do not use LabCorp may be responsible for paying significant laboratory
costs out of pocket. Check with your manager on your reimbursement process.
BOTH OPTIONS: If you meet criteria for other laboratory tests in the ‘Additional
Labs’ section that are not checked, your provider should order these for you. Please
indicate with a check mark on the form if any of these have been obtained.
COLLECT ALL RESULTS FROM THE PHYSICAN OR LABCORP. Return results
with final packet (STEP 5).
STEP 4 – Schedule/Visit your Dentist
You can schedule/visit your dentist any time after STEP 1 is complete.
Schedule an appointment with your dentist with this packet populated.
Have your dentist read the ‘Dear Dentist’ letter (page 29 of ‘Arctic PQ Packet’).
Have your dentist complete the ‘Arctic Dental Examination’ (page 30 of ‘Arctic PQ
Packet’).
Dentists can e-mail JPEG’s of dental x-rays directly to [email protected]
(preferred). Have the clinic CC you on the email in case they spell our email address
wrong. If Dentist is unable to e-mail JPEG’s of x-rays, then they should provide digital Xrays on a disk or film for Participants to include in the final packet. (FAXED X-RAYS
WILL NOT BE ACCEPTED)
Participants are responsible for payment of this examination. Then you can seek
reimbursement from your organization.
COLLECT ALL RESULTS FROM THE DENTIST. Return results with final packet
(STEP 5).
__________________________________________________________________________
Arctic PQ Information
4

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

STEP 5 – Package ALL forms in the ‘Arctic PQ Packet’ and lab/work up results and
return to CU Polar Medicine.
Keep a printed copy of your packet for your personal records.
Please email [email protected] to notify them when you have faxed or
mailed your PQ packet.
Preferred method of packet submission is by fax for speed of delivery. You can fax the
complete packet to 303-724-5649 but X-rays cannot be faxed and must be physically mailed
or emailed to [email protected]. For verification that your packet was received
by CU Polar Medicine, request a print of the fax confirmation page and save this for proof of
time, date, fax #, and verify full transmission page numbers.
You cannot send this packet to CU Polar Medicine as an email attachment because
of federal security regulations. Packets and forms sent via email will be deleted
without being read.
Alternatively, completed packets may also be sent by USPS/FedEx/UPS/Express Mail
with any additional forms and x-rays received by your physician and dentist. Keep the
tracking number for your records. Send the entire packet to CU Polar Medicine at:
If shipping by USPS (preferred mailing service):
CU Polar Medicine
Attn: Kellie Schiller, Elaine Reno
Mail Stop C328
12631 E 17th Ave, Room 2509, Aurora, CO
80045

If shipping by FedEx, UPS, DHL or any other mailing
service:
CU Polar Medicine, Dept of Emergency Medicine
Attn: Kellie Schiller, Elaine Reno
12631 E 17th Ave, Aurora CO 80045
Academic Office One, Room 2509
802-275-6367

THE HEALTH QUESTIONS AND TESTING REQUIREMENTS INCLUDED HEREIN ARE INTENDED TO ASSESS YOUR
SUITABILITY FOR DEPLOYMENT UNDER THE AUSPICES OF THE NATIONAL SCIENCE FOUNDATION’S OPERATIONS
IN THE ARCTIC REGIONS. THE PQ PROCESS IS NOT A SUBSTITUTE FOR YOUR OWN RESPONSIBILITY TO MANAGE
YOUR HEALTH CARE OR YOUR PHYSICIAN’S JUDGMENT IN DETERMINING YOUR HEALTH CARE NEEDS. THE TESTS
REQUIRED FOR YOUR PQ PROCESS ARE DETERMINED NOT ONLY ON THE BASIS OF RECOMMENDED MEDICAL
PRACTICE BUT ALSO ON THE ESTIMATED LENGTH OF YOUR STAY, WHERE YOU ARE SCHEDULED TO WORK, AND
THE AVAILABILITY OF TRANSPORTATION TO HIGHER-LEVEL HEALTH CARE FACILITIES.
All participants are responsible for their results and following up/reporting results to their
physician. In the event of any abnormal results, it is the participant's responsibility to follow-up with
their provider to evaluate these and receive further management/care.

CU Polar Medicine does not handle health care reimbursements. Please contact your
employer for reimbursement details. For additional questions, please contact CU Polar
Medicine at [email protected].
Thanks,
CU Polar Medicine (Medical provider for Arctic Support Contract)
Arctic PQ Information

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CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

National Science Foundation
U.S. ARCTIC PROGRAM PHYSICAL QUALIFICATION IMPORTANT INFORMATION
4201 WILSON BOULEVARD, SUITE 755
ARLINGTON VA, 22230

U.S. Arctic Program Physical Qualification Important Information
The Arctic is remote, with a harsh environment and limited medical facilities. Because of this,
all grantees, employees, and technical representatives are required to pass stringent medical
and dental examinations before deploying to the Ice.

Electronic Submission of Medical Forms
The National Science Foundation (NSF) is bound by the requirements of the Privacy Act of
1974 and its amendments. All information collected for the purpose of determining your
physical qualifications for deploying to the Arctic is considered confidential. NSF and its
contractors that are in receipt of your medical and personal information are required to
maintain your confidentiality and secure your information. NSF currently is unable to secure
data that is transmitted electronically and therefore cannot protect your confidentiality if you
transmit the data over unsecured lines.
In order to ensure that there is no violation of the Privacy Act or any other federal law
pertaining to confidential or personally identifiable information, CU Polar Medicine has been
instructed not to accept any electronically submitted medical forms.
Any medical forms received by email will be disposed of without action.
If you have any question regarding NSF privacy rules or procedures, please contact the NSF
Office of the General Counsel at (703) 292-8060.

Changes in Medical Condition

You are required to report any changes in your health status that occur after your physical
examination to CU Polar Medicine by mail or by email at [email protected].
Failing to do so may result in a denial of your application for assignment to the Arctic regions.
Willfully providing false statements to a Federal agency or its representatives is a criminal
offense.

Important Insurance Notice for Grantees
NSF does not provide insurance for grantee personnel while en route or in the Arctic, and it
does not fund acquisition of this insurance as a direct cost in its research grants.
Persons traveling to the Arctic under the award are expected to have insurance appropriate
to theirsituations and to ensure that all such insurance provides coverage in foreign
countries and during transit between their home institutions and the port of embarkation for
the Arctic so that any needed medical care, compensation for property loss, worker's
compensation, or survivor benefits will be covered. The awardee should ensure that all team
members, including but not limited to non- employees such as graduate students and
volunteers, have appropriate insurance.
Arctic PQ Information

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CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

Check your insurance policies to be sure that flights aboard scheduled military aircraft and
work on research vessels are covered.
All team members (paid or volunteer) traveling to the Arctic should be affiliated in some
manner withyour organization(s), so that any worker's compensation issues arising from
injuries sustained while deployed can be addressed by your organization.

Privacy Notice- Medical Examination Records for Service in
Arctic Regions
The National Science Foundation's Division of Arctic Programs is responsible for ensuring
that all personnel traveling to the Arctic under the auspices of the Arctic Program meet
certain medical standards, as outlined in 45 Code of Federal Regulations Section 675 (62
Fed. Reg. 31521 (June 10, 1997). This medical screening process requires that certain
medical records be generated on each individual participating in the Arctic Program.
The information requested on the Arctic Program provided forms is solicited under the
authority of the National Science Foundation Act of 1950, as amended, 42 U.S.C. 1870 et seq.
It will be used by NSF and its contractors and subcontractors in the medical screening process
to determine whether an applicant is qualified for deployment to the Arctic. An individual
medical file will include information collected to determine whether one is qualified for an
Arctic assignment, as well as clinical files that may be generated if one receives medical
treatment in the Summit Station medical clinic or any medical facilities in the Arctic arranged
by the Arctic Program.
The records are used for three primary purposes: (1) to determine the individual's fitness for an
Arctic assignment, including individual waiver requests; (2) to assist in determining an
appropriate course of medical/dental treatment should the individual seek medical care with
any medical care provider while in the Arctic; and (3) to provide documentation for addressing
quality of care issues associated with these medical functions.
Records contained within this system may be released to individuals involved in those three
functions. Such individuals include, in addition to designated NSF employees as needed for
assigned duties: (a) designated medical care practitioners and their administrative support
personnel involved in determining an individual’s fitness for an Arctic assignment, including
individual waiver requests; (b) medical care providers in NSF-supported stations and field
camps in the Arctic regions where the individual is assigned; and (c) medical experts advising
NSF on quality of medical care issues associated with NSF’s Arctic research programs. In
addition to these purposes, information in the medical records may be released to the
individual’s personal or examining physician or the individual’s designated emergency point of
contact when disclosure is necessary to determine initial medical clearance or to review
treatment options if the individual requires medical attention while on assignment in the Arctic
regions. The determination of whether the individual is physically qualified/not physically
qualified (PQ/NPQ) may be released to representatives of the individual’s sponsoring
organization, including academic institutions and investigators on a grant, to inform them
whether an individual is approved for deployment or not.
Arctic PQ Information

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CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

If necessary, information may be released to federal, state, or local agencies, or foreign
governments when disclosure is necessary to obtain records in connection with an investigation
by or for NSF; and to another federal agency, a court, or a party in litigation before a court or in
an administrative proceeding if the government is a party, or when NSF determines that the
litigation or anticipated litigation or proceeding is likely to affect the Agency.
Submission of the information requested is voluntary. However, if you fail to provide any of
the requested information, NSF, or its contractor, may be unable to process or to approve your
application for Arctic deployment.
More detail about how and where these records are maintained in accordance with the Privacy
Act, 5 U.S.C. 552a, is contained in the National Science Foundation's System of Record Notice,
Medical Examination Records for Service in the Arctic Regions, available upon request from
NSF. 1 No disclosure of information contained in your medical file will be made except as described by NSF's
System Notice or as otherwise authorized by law. You may request a copy of your record for review.
1 For a copy of the System Notice, please contact the Division of Arctic Programs Safety and Occupational Health Manager at
NSF at (703) 292-7438, or write to Safety and Occupational Health Manager, Division of Arctic Programs, National Science
Foundation, 4201 Wilson Blvd., Suite 755, Arlington, VA 22230.

Pursuant to 5 CFR 1320.5(b), an agency may not conduct or sponsor, and a person is not
required to respond to an information collection unless it displays a valid OMB control
number. The OMB control number for this collection is 3145-0177. Public reporting burden
for this collection of information is estimated to average 9.6 hours per response, including the
time for reviewing instructions. Send comments regarding this burden estimate and any other
aspect of this collection of information, including suggestions for reducing this burden, to:
Suzanne Plimpton, Reports Clearance Officer, Office of the General Counsel, National Science
Foundation, Arlington, VA 22230.

Influenza Vaccination
Every deploying Arctic participant is required to receive an influenza vaccination prior to
deployment based on availability. Participants should obtain a flu shot from their medical
provider at least two weeks prior to deployment and submit the supporting documentation to
CU Polar Medicine. Receiving the vaccination is a condition of your deployment. Exemptions
based on medicalreasons will be considered on an individual basis.
If you have had a severe reaction to a flu shot in the past (severe reaction is throat, mouth or
airway swelling, difficulty breathing, rash or hives), then submit documentation from the
treating physician or emergency room. If you have a proven severe reaction to egg protein
(same symptoms as above), then submit report from your physician or allergist. With proper
documentation, you will be exempted from the requirement. Localized reactions associated
with the flu shot may include mild problems such as soreness, redness, or swelling where the
shot was given. They are generally not serious and do not justify exemption from the annual
vaccination requirement.

Arctic PQ Information

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CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

To learn more about the flu vaccine, related benefits, risks, and precautions, contact
the CDC. Call 1-800-232-4636 (1-800-CDC-INFO)
Visit CDC’s website at http://www.cdc.gov/flu

Personal Prescription Medications
It is the responsibility of all participants to obtain a supply of their regular prescription
medications to cover the time that they will be deployed. The Arctic stations and vessels do
not have prescription medicines available to support personal prescriptions. Participants will
not be allowed to winter-over unless they have enough of their regular medications to last
through the winter season.

Deployment
If you have any questions about the procedure for transporting your prescription medications
to the Arctic, please contact the CU Polar Medicine at [email protected].
It is important that you hand carry the initial three months of medication (one month for
controlled medications) in order to provide enough time for the mail to reach you in the Arctic.
Most health plans only allow one month of medication to be dispensed at a time.

Eyewear Policy for Arctic
Everyone in the Arctic is required to wear sunglasses or other protective eyewear (e.g.
goggles)! You are traveling to a part of the world where scientists have documented increased
ultraviolet radiation because of depletion in the ozone layer. Snow and ice reflect 85% of
Ultraviolet Radiation (UVR) and can cause a serious, painful, and disabling condition known
as snow blindness. Appropriate protective eyewear is especially important on windy days to
protect against volcanic ash particles and snow blowing in the eyes.
The type of sunglasses or eye protection you wear while you are in the Arctic is very
important. Sunglasses must block 100% of the sun's Ultraviolet Rays. Some dark glasses do
not block UVR and cause the iris to widen and admit more light that can cause damage to the
eye. Frames must be non- metal to avoid injury to the skin from the cold. Retaining straps are
mandatory. Side protectors are recommended, but not required.

Prescription Eyewear:
If you wear prescription eyewear and choose to wear prescription sunglasses during your
deployment,the sunglasses must meet the above criteria. Please obtain a current prescription
from your ophthalmologist/optometrist (including pupillary distance) and bring it with you
when you deploy, in the event you need replacement eyewear while deployed. Contact lenses
can be worn in the Arctic.
Dry climate can cause difficulties. It is suggested that you carry your lenses on your person
to avoidpossible damage and/or freezing.
Bring extra pairs of glasses, prescription or non-prescription, in case of damage or loss.

Arctic PQ Information

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CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

National Science Foundation
Directorate for Geosciences
Office of Arctic Programs
06 October 2022
To: Arctic Research Program Participants
Subject: COVID-19 Vaccine and Bivalent Booster Requirements for Deploying Participants
1. On 23 August 2021, the Food and Drug Administration (FDA) granted full approval of the PfizerBioNTech COVID-19 vaccine. On 23 August 2021, the Office of Polar Programs implemented
requirements of COVID-19 vaccination in order to meet guidelines of the Physical Qualification
(PQ) process. On 15 December 2021, all participants deploying to one of the Antarctic stations
were required to receive a COVID-19 booster if the participant meets the Centers for Disease
Control and Prevention’s (CDC) recommendations for COVID-19 booster shots.
2. If deploying after 15 October 2022, in order to maintain a PQ status, all USAP participants must
obtain the bivalent booster that meets CDC’S COVID-19 vaccination and booster
recommendations for maintaining an up-to-date status (two months post completing the primary
series or two months post last booster). An exception exists if a participant has a confirmed case
(physician or laboratory) of COVID-19 within 60 days of deployment. In this situation, the
participant must agree to obtain the bivalent booster during deployment and once out of the 60day window. For participants that deployed prior to 15 October 2022 participants must receive
the bivalent booster while deployed to remain Physically Qualified for the 22-23 austral summer
and future seasons. Bivalent booster administration will begin on stations no later than 1
November 2022. Administration will be staggered and dependent on vaccine availability.
Deployed active-duty Department of Defense (DoD) personnel will follow DoD service guidance
for vaccination. Foreign participants will be reviewed on a case-by-case basis for determination
of requirements.
3. This decision is based on a risk benefit analysis, which included the current COVID-19 situation
(e.g. changes in community spread, available means of treatment and prevention, individual and
population health impact of COVID-19 vaccination, risk of COVID-19 to deployed individuals,
etc.), the impact the COVID-19 pandemic has and has had on meeting the OPP operational
mission, and the individual and collective impact one or more cases of COVID- 19 would have
on the OPP program.
4. Vaccination requirements will be updated as CDC continues to follow data related to vaccine
effectiveness and safety, waning immunity and protection against the virus.

Elicia Liles
Safety and Occupational Health Manager, GEO OPP
2415 Eisenhower Avenue | Alexandria, VA 22311

Arctic PQ Information

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CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
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Appendix 1 - Exercise Stress Testing (ETT)
Indications for screening cardiovascular stress test:
Summer Participant: required only if Framingham Risk Score (FRS) is score greater than
20%.
Winter Participant: Cardiovascular stress tests are required every two years from 50-59
and yearly after the age of 60.
http://cvdrisk.nhlbi.nih.gov/
Criteria for successful completion of cardiovascular stress test:
• Completion of an adequate standard Bruce Protocol stress test to at least 9 minutes,
• AND no symptomatic or electrocardiographic evidence of ischemia including chest
pain, marked dyspnea or claudication,
• AND normal increase in BP response to exercise,
• AND no significant ST depression, arrythmia, or exercise induced hypoxemia,
• AND greater than 85% of maximum heart rate achieved,
• AND sustained work level of 10 METS for 3 minutes (completion of stage 3 Bruce
Protocol),
• AND physician interpretation of “negative” or “low probability” of ischemia

Arctic PQ Information

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CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

APPENDIX 2: Protocol for TB Testing and Treatment
The revised protocol for TB TESTING AND TREATMENT was provisionally approved in March 2016.
Effective immediately, the Physical Qualification requirement related to TB TESTING AND TREATMENT is
modified as follows:
1.

Continue surveillance for TB disease.

2.
Provide instructions to the examining physician to determine the preferred initial TB screen based on
the participant’s answers to the PQ history questions:
a) Prior BCG vaccination: use QuantiFERON
b) Prior positive PPD due to prior infection with related mycobacterial (non-TB) infections, negative
exposure questions: use QuantiFERON
c) Report of prior positive PPD but with no information about the event: use QuantiFERON
d) Prior allergic response to PPD: use QuantiFERON
e) All others: use PPD
3. Use the TB screen result to determine additional screening requirements, where positive PPD or
QuantiFERON requires:
a) CXR
b) Symptom Questionnaire
4.
Revise the Guidelines so that if a participant has a positive TB screen result and then either the CXR
or the symptom questionnaire is positive, the participant has active TB and is NPQ until 9-months posttreatment with a follow-on clear chest x-ray.1
5. Revise the Guidelines so that if a participant has a positive TB screen result and then the CXR and the
symptom questionnaire is negative, the participant has latent TB and will not be deemed PQ until
treatment using accepted protocols has commenced.
The contracted health care provider shall review the attached Position Paper and implement Recommendations
1 through 3 consistent with that guidance. Proposed revisions to the Physical Qualification Packet and to the
Medical Screening Guidelines for Restricted Clearance, Unrestricted Clearance, and Not Physically Qualified
have been submitted to POLAR for review and are approved for implementation.
This change applies to all NSF staff, grantees, contractors, and visitors required to physically qualify for
deployment to the Arctic. I request your assistance in widely disseminating this information to affected
entities and individuals.
Points of contact regarding this matter is Ms. Nadene Kennedy [email protected].
Susanne M. LaFratta
Section Head, Polar Environment, Safety & Health
enclosure:
cc:

Position Paper

Arctic Support Contractor NSF Health Unit

1

A waiver may be positively considered for critical positions when the participant is 2-months post-treatment with signs of
resolution.

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CU Polar Medicine
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POSITION PAPER
SUBJECT:
REVISION TO PROTOCOL FOR TB TESTING AND TREATMENT
BACKGROUND:
NSF-funded researchers and support personnel traveling to certain, remote parts of the Arctic must also
undergo and pass the PQ process.
The PQ process is designed to identify personnel who are physically qualified and, additionally for
winter-over candidates, psychologically adapted for assignment in the polar regions. The PQ process is
necessary to identify the presence of any physical or psychological condition that would threaten the
health or safety of the candidate or of other program participants, that could not be effectively treated by
the limited medical care capabilities in the Arctic, or that otherwise pose a risk that would jeopardize
accomplishment of objectives. Also important during any season, summer or winter, are the costs of lost
productivity and the diversion of limited resources that results when deployed personnel are unable to
perform their assigned function.
The PQ process is not, however, intended as a substitute for an individual’s responsibility to manage his
or her own health care. To ensure that individuals understand this limitation of the PQ process, the forms
that individuals and their doctors are required to review, complete, and sign carry a legend that makes this
point abundantly clear:
THE HEALTH QUESTIONS AND TESTING REQUIREMENTS INCLUDED HEREIN ARE
INTENDED TO ASSESS YOUR SUITABILITY FOR DEPLOYMENT UNDER THE AUSPICES
OF THE NATIONAL SCIENCE FOUNDATION’S OPERATIONS IN THE ARCTIC REGIONS.
THE PQ PROCESS IS NOT A SUBSTITUTE FOR YOUR OWN RESPONSIBILITY TO
MANAGE YOUR HEALTH CARE OR YOUR PHYSICIAN’S JUDGMENT IN DETERMINING
YOUR HEALTH CARE NEEDS. THE TESTS REQUIRED FOR YOUR PQ PROCESS ARE
DETERMINED NOT ONLY ON THE BASIS OF RECOMMENDED MEDICAL PRACTICE
BUT ALSO ON THE ESTIMATED LENGTH OF YOUR STAY, WHERE YOU ARE
SCHEDULED TO WORK, AND THE AVAILABILITY OF TRANSPORTATION TO HIGHERLEVEL HEALTH CARE FACILITIES.
POLAR will rely on many sources when proposing changes to its PQ process. Primarily, but not limited
to,
• the contracted health care providers that have the best information about the deployed
population’s health care needs and the services provided by the clinics and other emergency
personnel;
• the Medical Review Panel chartered in part to assist POLAR with identifying medical conditions
that are incompatible with safe and productive deployment or to identify medical tests that are
predictive and cost effective or alternatively unnecessary and lacking in predictive value;
• the U.S. Preventive Services Task Force, an independent, volunteer panel of national experts in
prevention and evidence-based medicine that makes evidence-based recommendations about
clinical preventive services such as screenings, counseling services, and preventive medications;2
2
According to its website, the Task Force is funded, staffed, and appointed by the U.S. Department of Health and Human Services’
Agency for Healthcare Research and Quality. Members come from the fields of preventive medicine and primary care, including
internal medicine, family medicine, pediatrics, behavioral health, obstetrics and gynecology, and nursing. Their recommendations

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•

and,
Syntheses and systematic comparisons of selected guidelines that address similar topic areas may
also be instructive.3

CONTEXT:
Tuberculosis (TB) is caused by the infective agent Mycobacterium Tuberculosis. It is one of the oldest
diseases known to be associated with man with descriptions of the infection dating back to the earliest of
human records. It remains a major cause of disease and death worldwide justifying continued
surveillance. Unlike other diseases that have been eradicated or controlled by human intervention, there
has been little success in eradicating TB although the incidence has dropped an estimated 1.5% annually
in the recent past. At the same time, emergence of drug resistant and extensively drug resistant strains
continue to concern infectious disease specialists.4
While the US incidence of disease is low, this is not true for other countries of the world. The World
Health Organization (WHO) reported 5.7 million new cases in 2013, of which 95% were in developing
countries. WHO reports that actual disease burden is likely as much as one-third higher due to under
reporting of disease from third-world countries. WHO estimates an annual disease burden of 9 million
new cases a year with 1.5 million deaths due to TB worldwide.
There were 9,572 cases of new TB reported in the United States in 2013.

are based on a rigorous review of existing peer-reviewed evidence and are intended to help primary care clinicians and patients
decide together whether a preventive service is right for a patient's needs. The Task Force explicitly does not consider cost as a
factor in its recommendations.
3
Syntheses are developed by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality.
Key elements of each synthesis include a discussion of areas of agreement and difference, the major recommendations and the
corresponding strength of evidence and recommendation rating schemes, and a comparison of guideline methodologies. Also
presented are the source(s) of funding, the benefits/harms of implementing the guideline recommendations, and any associated
contraindications.
4
Harrison’s Internal Medicine.

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Transmission is via airborne droplets propelled by cough. Droplet size is small so may remain suspended
in the air for several hours. Inhaled droplets readily deposit in small alveoli in the lungs, aiding infection.5
Adequate infection control processes including hospital grade disinfectants, patient and provider masks
and UV treatment result in low transmission rates although it can take months to a year from when a
patient typically becomes actively infected for the index case to be identified.
If properly treated TB caused by drug susceptible strains is highly curable. If left untreated mortality is as
high as 50-65% within 5 years.
Recent examples of TB exposure in the US:
-March 2015, a Kansas high school student was diagnosed with TB requiring testing of over 300 students
and employees. 27 students tested positive and will require up to 9 months of treatment.
-100 students in a Seattle college had to be tested after a student tested positive.
-In Pittsburgh, PA, a student tested positive for active TB leading officials to recommend that every
student in the school be tested.
-September 2015, a nurse working in a maternity ward exposed 859 babies in 2013-2014. 5 infants
eventually tested positive for TB.
-In 2013, 126 students tested positive in Riverside, CA, after a student was diagnosed with active TB.
-Since January 2016, 3 adults died and 26 people were confirmed with active TB in Marion County,
Alabama. “This is a case rate of 253 per 100,000 population in the town of Marion. This far exceeds the
TB case rate of 2.5 per 100,000 in the whole state of Alabama in 2015”.6
As shown, the requirements for evaluation and treatment of potential TB exposures can be quite
burdensome and would easily overcome the ability of the polar stations and vessels to evaluate and treat
cases.
Testing Process:
“Targeted testing is an essential TB prevention and control strategy that is used to identify, evaluate, and
treat persons who are at high risk for latent tuberculosis infection (LTBI) or at high risk for developing
5

Id.
6
Alabama Department of Public Health public information release

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TB disease once infected with M. tuberculosis. Identifying persons with LTBI is important to the goal of
TB control and elimination because treatment of LTBI can prevent infected persons from developing TB
disease and stop the further spread of TB. All testing activities should be accompanied by a plan for
appropriate follow-up medical evaluation and treatment. Necessary medical evaluation and treatment
resources need to be identified before testing activities begin.7 Once active TB disease has been excluded,
treatment of LTBI should be offered to patients regardless of their age, unless medically contraindicated.”
Arctic personnel will be referred to their personal health care providers for treatment.
Normally the US population would not be considered high risk for TB testing. However, the Centers for
Disease Control (CDC) risk assessment tool suggests testing populations who travel in areas where
infection is prevalent. A significant percentage of the polar population is known to travel to areas of
endemic TB infection (Asia, Africa, South and Central America, Russia). Additionally, the POLAR
population tested and proven to have latent TB have thus far been either foreign born or have known
travel to high-risk countries. The CDC further suggests testing of higher risk populations living in
congested housing situations (e.g., dorms, barracks).
Considering the risk of TB exposure in a population that frequently reports travel to areas with reported
high disease burdens, the close living shared by participants and the expense and difficulty in evaluating
Arctic station populations, continued active surveillance for TB and a modification to the testing methods
is recommended.
Testing Methods:

There is a two-step approach to testing for TB. The first entails testing for possible exposure using either
a purified protein derivative (PPD) skin test or an IGRA blood test (e.g., QuantiFERON). Both tests have
known weaknesses and they are not used to confirm the other except in special cases. Sensitivity (positive
in presence of disease) is in the 60-90% range for both of these tests and it is quite possible for one test to
be positive and the other negative in a patient with TB disease.
The recommended first test in most cases remains the PPD. Guidelines exist for interpreting positive
results depending on the patient’s pre-existing risks.
The QuantiFERON test, which is more expensive, should be substituted for the PPD in people with a
prior history of BCG vaccine,8 prior infection with related mycobacterial (non-TB) infections and allergic
responses. The benefit of testing with QuantiFERON for these people is the ability to differentiate
between false positives and a true positive PPD test. QuantiFERON is also appropriate for individuals
that report a previous positive PPD but who do not have information about the event.
Positive results from either the skin test or the blood test require a chest X-ray (CXR) and a questionnaire
to exclude active disease. POLAR’s current practice of requiring a CXR alone is inadequate to exclude
active TB disease, thus inclusion of a testing survey as part of the evaluation for either a positive PPD or
QuantiFERON test is recommended.
Patients who have a positive test and a negative CXR with negative responses to symptom questions are
considered to have latent TB. Latent TB is defined as a patient who has previously been exposed to TB
but whose immune system is currently able to suppress the infection. These patients are not currently, but
could in the future become, infectious and should be treated to prevent conversion to active TB and to
7

http://www.cdc.gov/tb/publications/ltbi/targetedtesting.htm
8
According to the CDC website, BCG, or bacille Calmette-Guerin, is a vaccine for tuberculosis (TB) disease used in many
countries with a high prevalence of TB.

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prevent risk of transmission to others within the program.

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An estimated 10% of patients with latent TB will convert to active TB disease over their lifetime. 5% of
that risk occurs in the first two years with the remaining 5% occurring over the patient’s lifetime.
Conversion to active disease is increased in the elderly, patients with HIV or who are otherwise immune
suppressed either due to disease or medications used to treat certain disease, such as corticosteroids or
immune modulators.
It should be noted that POLAR does not make the treatment recommendation for a participant. The
decision to treat in the US would generally consider the risk to the patient from a relatively rare drug
reaction versus the risk of transmission. It would not be unreasonable for a treating physician in the US to
elect not to treat a specific patient when considering the risks of medication reactions versus the ability to
actively survey the patient and intercede in the process if the patient were to develop active TB.
The CDC notes, however, that transmission risks are greatly increased for people who spend time in
enclosed spaces with people who have active TB. They also note that it is important for people living in
congested housing situations to have processes in place to minimize such transmission including prompt
detection, airborne precautions and active surveillance. Given the potential risks should an individual with
latent TB reactivate into active disease, thus potentially infecting countless individuals at an Arctic station
– and especially in the winter with limited medical support and no chance of evacuation – changes to TB
screening and the TB guidelines are recommended as noted below.
RECOMMENDATIONS:
The recommendations noted below take into account the recommendations made by the Center for Polar
Medical Operations and the Medical Review Panel.
POLAR participants with latent TB should not be qualified for deployment unless they have been treated
to prevent conversion to active TB and to prevent risk of transmission to other participants.
1.

Continue surveillance for TB disease.

2.
Provide instructions to the examining physician to determine the preferred initial TB screen based
on the participant’s answers to the PQ history questions:
f) Prior BCG vaccination: use QuantiFERON
g) Prior positive PPD due to prior infection with related mycobacterial (non-TB) infections, negative
exposure questions: use QuantiFERON
h) Report of prior positive PPD but with no information about the event: use QuantiFERON
i) Prior allergic response to PPD: use QuantiFERON
j) All others: use PPD
4. Use the TB screen result to determine additional screening requirements, where positive PPD or
QuantiFERON requires:
c) CXR
d) Symptom Questionnaire
4.
Revise the Guidelines so that if a participant has a positive TB screen result and then either the
CXR or the symptom questionnaire is positive, the participant has active TB and is NPQ until 9-months

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post-treatment with a follow-on clear chest x-ray.9

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6. Revise the Guidelines so that if a participant has a positive TB screen result and then the CXR and the
symptom questionnaire is negative, the participant has latent TB and will not be deemed PQ until
treatment using accepted protocols has commenced.
The purpose of testing and the recommended changes to the guidelines are for the purposes of
determining whether an individual is qualified to deploy to polar regions. The American Thoracic
Society and the CDC emphasize that administering the tests implies a commitment to administer therapy
and this responsibility remains with the examining physician.10

9

A waiver may be positively considered for critical positions when the participant is 2-months post-treatment with signs of
resolution.
10 http://cid.oxfordjournals.org/content/34/3/365.full

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CU Polar Medicine
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Vaccinations and Infectious Disease

The PQ Determination Policy concerning vaccinations primarily follows the recommendations
of the Center for Disease Control and Prevention (CDC) and the Advisory Committee on
Immunization Practices (ACIP). Any immunizing agent licensed by the Food and Drug
Administration (FDA) or the Department of Health and Human Services (DHHS) may be used,
as well as emergency use authorization (EUA) process. The requirements are based on CDC
recommendations, host country requirements and OPP's Medical Review Panel.
Required Vaccinations:
• Tetanus
• Seasonal Influenza (exception for Arctic participants deploying in late spring/summer)
• Measles
• COVID-19 (CDC up-to-date recommendations)- Must complete at least 14 days prior to
deployment.
Required Infectious Disease Testing:
• Hepatitis A
• Hepatitis B
• HIV (USAP only: Walking Bloodbank, for winter deployers)
• Syphilis (RPR)
• Tuberculosis
Screening for immunity. For some vaccine–preventable diseases, serologic or other tests can
be used to identify preexisting immunity from prior infection or immunization that may
eliminate the need for unnecessary immunization. Such testing may be adopted where it offers
advantages in terms of improved care or medical economics. Titers may be used for measles.

*** Please provide written documentation of all required vaccinations, and any additional
non-required vaccinations if you have them, so that we may keep these on record.
Written documentation can be your most recent vaccination record, a clinic notes from your
physician’s office (printed from the physician clinic, etc.), or a receipt from a pharmacy with
your name, date of birth, and date vaccination was given.

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CU Polar Medicine
Mail Stop C328
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International Physical Qualifications (PQ)
International PQ is allowed in Primary English-Speaking countries:
UK, Australia, New Zealand, U.S.

PQ in other countries is also allowed with translation services. See information below.
Other translators may meet criteria, check with CU Polar Medicine for pre-approval.
(Prior to visiting doctors in other countries).
Please contact CU Polar Medicine at [email protected] or 1-802-275-6367.
Translation Document
All PQ documents must be translated into English for submission. Translations must be typed
and certified by approved translation services. Translators that are members of the
organizations below are known to be acceptable. Other local services may also meet criteria so
please contact us with the information prior to arranging and paying for translation services.
Worldwide
•
•
•
•
•
•
•

International Federation of Translators
International Association of Professional Translators and Interpreters
International Association of Conference Interpreters
International Association for Translation and Intercultural Studies
Translators Without Borders
European Society for Translation Studies
Tremédica

Canada
•

Canadian Translators, Terminologists and Interpreters Council

France
•

Union Nationale des Experts Traducteurs Interprètes près les Cours d'Appel

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HIPAA and Polar Programs
NSF/OPP Screening of Personnel Traveling to Antarctica under the US Antarctic Program
The National Science Foundation’s Office of Polar Programs is responsible for ensuring that all
personnel traveling to Antarctica under the auspices of the United States Antarctic Program
(USAP) meet certain medical standards, as outlined in 45 Code of Federal Regulations Section
675 (62 Fed. Reg. 31521 (June 10, 1997). Medical screening examinations are necessary to
determine the presence of any conditions which would threaten the health or safety of an
individual or other USAP participants while deployed, or that could not be effectively treated by
the limited medical care capabilities in Antarctica. This medical screening process requires that
certain medical records be generated on each individual seeking to participate in the USAP.
NSF solicits the information requested on USAP-provided forms under the authority of the
National Science Foundation Act of 1950, as amended, 42 U.S.C. 1870. NSF and its contractors
use this information in the medical screening process to determine whether an applicant is
qualified for safe deployment to Antarctica. An individual medical file will include information
collected to determine whether one is qualified for Antarctic assignment, as well as clinical files
that may be generated if one receives medical treatment in any of the USAP medical clinics in
Antarctica. These records are maintained in NSF's Privacy System of Records, NSF-19,
"Medical Examination Records for Service in the Polar Regions."
The records are used for three primary purposes: (1) to determine the individual’s fitness for
Antarctic assignment, including individual waiver requests; (2) to assist in determining an
appropriate course of medical/dental treatment should the individual seek medical care with any
medical care provider while in Antarctica; and (3) to provide documentation for addressing
screening and quality of care issues associated with these medical functions.
HIPAA Inapplicable to USAP Medical Screening and Care Records
Travel to the polar regions imparts risk to the traveler because of harsh environmental
conditions, limitations in the medical care available, and difficulties, in emergencies, in
providing timely evacuation to tertiary medical care facilities. The USAP screening process
seeks to manage these risks by limiting deployment to those who can be effectively treated by
the medical care facilities in the remote locations where they will be deployed. No infrastructure
exists where USAP participants are deployed, other than that provided by the USAP, and these
facilities naturally cannot include the expensive tertiary care needed to, for example, conduct
major surgery.
USAP does provide primary medical or health care to USAP participants while deployed at
remote locations when needed.1 However, that medical care does not fall within the definition of
"health care provider" in the Health Insurance Portability and Accountability Act of 1996

1
*Health care" means care, services, or supplies related to the health of an individual. It includes, but is not limited
to, the following: (1) Preventive, diagnostic, rehabilitative, maintenance, or palliative care, and counseling, service,
assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that
affects the structure or function of the body; and (2) Sale or dispensing of a drug, device, equipment, or other item in
accordance with a prescription. See 45 C.F.R.160.103.

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(HIPAA). Thus, the limited USAP health screening and limited health care facilities and
treatment at remote cites are not a "covered entity" subject to HIPAA regulations.
The HIPAA Standards
Administrative Simplification standards adopted by HHS under the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) apply to a "covered entity." For our purposes here that
is a health care provider that conducts certain "transactions" in electronic form.2 Thus, to be a
covered entity the USAP must meet three elements: (1) health care provider 3 that (2) conducts
certain "transactions" (3) in electronic form.4
"Transaction" means the exchange of information between two parties to carry out financial or
administrative activities related to health care. It includes the following types of information
exchanges:
(1) Health care claims or equivalent encounter information.
(2) Health care payment and remittance advice.
(3) Coordination of benefits.
(4) Health care claim status.
(5) Enrollment and disenrollment in a health plan.
(6) Eligibility for a health plan.
(7) Health plan premium payments.
(8) Referral certification and authorization.
(9) First report of injury.
(10) Health claims attachments.
(11) Other transactions that the Secretary may prescribe by regulation.
A transaction is a covered transaction if it meets the regulatory definition for that type of
transaction. The only covered transaction that might apply to the USAP is the regulatory
definition of “Health care claims or equivalent encounter information.”5
Health care claims or equivalent encounter information transaction is either of the
following: (a) A request to obtain payment, and necessary accompanying information, from a
2

The definition also includes a health care clearinghouse, or a health plan. The USAP is neither a health care
clearing house, nor a health care plan. See 45 C.F.R.160.103.
3
A" health care provider" means a provider of medical or health services, and any other person or organization that
who furnishes, bills, or is paid for health care in the normal course of business. See 45 C.F.R.160.103.
4
Electronic media means: (1) Electronic storage media including memory devices in computers (hard drives) and
any removable/transportable digital memory medium, such as magnetic tape or disk, optical disk, or digital memory
card; or (2) Transmission media used to exchange information already in electronic storage media. Transmission
media include, for example, the internet (wide-open), extranet (using internet technology to link a business with
information accessible only to collaborating parties), leased lines, dial-up lines, private networks, and the physical
movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via
facsimile, and of voice, via telephone, are not considered to be transmissions via electronic media, because the
information being exchanged did not exist in electronic form before the transmission.
Individual medical files created by the USAP medical screening process or in providing medical care in Antarctica
are collected and maintained in paper form.
5

Transactions for which the Secretary of HHS has adopted standards are at 45 C.F.R. Part 162. None of the current
standards for “health care claims or equivalent encounter information” transactions apply to USAP activities either.
45 CFR 162.1102.

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health care provider to a health plan, for health care. (b) If there is no direct claim, because
the reimbursement contract is based on a mechanism other than charges or reimbursement
rates for specific services, the transaction is the transmission of encounter information for the
purpose of reporting health care. 45 C.F.R.162.1101.
The USAP is not a health plan, nor does it request payment, nor pay for medical claims, specific
medical services, or individual medical encounters.
USAP Reimburses for a Level of Medical Services, Not for Individual Claims or Encounters
All USAP participants are required to meet medical clearance criteria per the standards set out in
45 USC 675.3. USAP’s contract for Antarctic infrastructure and support systems includes,
among many things, contractor responsibility for operating a medical screening system. Through
it the contractor determines whether grantee personnel, NSF and certain other federal employees,
employees of other contractors and subcontractors, and the contractor’s own employees meet the
prescribed medical criteria, and are “physically qualified” (PQd) or “not physically qualified”
(NPQd) for deployment. Those who fail to qualify may request a waiver in accordance with the
NSF waiver process. 45 CFR 675.4. The Director of the NSF Office of Polar Programs makes
the final determination on waivers.
In addition to its screening duties, the USAP contractor is required to operate clinics at three sites
in Antarctica. These clinics must be operated as Level III trauma centers and include appropriate
care for injuries prevalent in the extreme conditions in Antarctica, e.g., hyperbaric medicine and
cold injuries.
The contract is a cost-plus-award-fee contract. NSF reimburses its contractor for all labor,
material, equipment, and other direct costs associated with providing the specified level of
medical service capability required under the contract. These services are not acquired on a feefor-service or per-transaction basis, or other type of fixed rate schedule. Therefore, these
medical services do not meet the HIPAA definition of “Health care claims or equivalent
encounter information,” and the USAP is not a “covered entity” for HIPAA.
USAP Medical Records Are Covered by the Privacy Act of 1974
Although HIPAA does not apply to these records, they are protected by the Privacy Act’s
restrictions. As noted, USAP medical files are records maintained in NSF's Privacy Act System
of Records, NSF-19, "Medical Examination Records for Service in the Polar Regions." The
Privacy Act notice accompanying the medical clearance forms clearly informs applicants for
deployment why the information is requested and what uses will be made of it. (See
attachment.) In addition, NSF and its contractors have implemented confidentiality and security
procedures commensurate with the private nature of medical records.

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-------------------------------------------------------------------------------------------------PRIVACY NOTICE
Medical Examination Records for Service in Polar Regions
The National Science Foundation’s Office of Polar Programs is responsible for ensuring that all
personnel traveling to Antarctica under the auspices of the United States Antarctic Program
(USAP) meet certain medical standards, as outlined in 45 Code of Federal Regulations Section
675 (62 Fed. Reg. 31521 (June 10, 1997). This medical screening process requires that certain
medical records be generated on each individual participating in the USAP.
The information requested on USAP provided forms is solicited under the authority of the
National Science Foundation Act of 1950, as amended, 42 U.S.C. 1870. NSF and its contractors
use the information in the medical screening process to determine whether an applicant is
qualified for deployment to Antarctica. An individual medical file will include information
collected to determine whether one is qualified for Antarctic assignment, as well as clinical files
that may be generated if one receives medical treatment in any of the USAP medical clinics in
Antarctica.
The records are used for three primary purposes: (1) to determine the individual’s fitness for
Antarctic assignment, including individual waiver requests; (2) to assist in determining an
appropriate course of medical/dental treatment should the individual seek medical care with any
medical care provider while in Antarctica; and (3) to provide documentation for addressing
quality of care issues associated with these medical functions.
Records contained within this system may be disclosed to individuals involved in those three
functions. Such individuals include, in addition to designated NSF employees as needed for
assigned duties: (a) designated medical care practitioners and their administrative support
personnel involved in determining an individual’s fitness for Antarctic assignment including
individual waiver requests; (b) medical care providers in NSF-supported stations and field camps
in the polar regions where the individual is assigned; and (c) medical experts advising the NSF
on quality of medical care issues associated with NSF’s polar research programs. In addition to
these purposes, information in the medical records may be released to the individual’s personal
or examining physician or the individual’s designated emergency point of contact when
disclosure is necessary to determine initial medical clearance or to review treatment options if
the individual requires medical attention while on assignment in the polar regions. The
determination of whether the individual is physically qualified/not physically qualified
(PQ/NPQ) may be released to representatives of the individual’s sponsoring organization
including academic institutions, and investigators on a grant to inform them whether an
individual is approved for deployment or not.
If necessary, information may be released to Federal, state, or local agencies, or foreign
governments when disclosure is necessary to obtain records in connection with an investigation
by or for the NSF; and to another Federal agency, a court, or a party in litigation before a court or

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in an administrative proceeding if the government is a party, or when NSF determines that the
litigation or anticipated litigation or proceeding is likely to affect the Agency.
Submission of the information requested is voluntary. However, if you fail to provide any of the
requested information, NSF or its contractor may be unable to process or to approve your
application for polar deployment through the USAP.
More detail about how and where these records are maintained in accordance with the Privacy
Act, 5 U.S.C. 552a, is contained in the National Science Foundation’s System of Records Notice,
Medical Examination Records for Service in the Polar Regions, available upon request from the
NSF. No disclosure of information contained in your medical file will be made except as
described by the NSF’s System Notice or as otherwise authorized by law. You may request a
copy of your records for review.

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Notice of Privacy Practices
Effective: April 22, 2019
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
University of Colorado Health (“UCHealth”) is required by law to maintain the privacy of your health information and
provide you a description of our privacy practices. This notice applies to any hospital or health care facility that UCHealth
operates, whether directly or through one of its subsidiaries, including members of the UCHealth Affiliated Covered Entity
which includes: Longs Peak Hospital; UCHealth Ambulatory Surgery Centers d/b/a UCHealth Longs Peak Surgery
Center, UCHealth Cherry Creek North Surgery Center, UCHealth Inverness Orthopedics and Spine Surgery Center;
Medical Center of the Rockies; Poudre Valley Health Care, Inc.; Poudre Valley Medical Group, LLC d/b/a UCHealth
Medical Group; UCHealth Broomfield Hospital; UCHealth Grandview Hospital; UCHealth Community Services; UCHealth
Emergency Physicians Services, LLC; UCHealth Greeley Hospital; UCHealth Highlands Ranch Hospital; UCHealth Pikes
Peak Regional Hospital; UCH-MHS d/b/a Memorial Health Systems; University of Colorado Hospital Authority; Yampa
Valley Medical Center d/b/a UCHealth Yampa Valley Medical Center; UCHealth Imaging Services, LLC; and any other
members that may be found at www.uchealth.org. This notice applies to all UCHealth employees, staff, volunteers,
students, trainees and others whose conduct, in the performance of work for UCHealth, is under the direct control of
UCHealth, whether or not they are paid by UCHealth.
This notice also applies to other health care providers that offer clinically integrated health care services at UCHealth
facilities, such as physicians, residents, physician assistants, emergency service providers, and others as part of an
Organized Health Care Arrangement. However, this notice only applies to the privacy practices of these health care
providers when they are providing care at an UCHealth facility. It does not apply to the privacy practices of these
providers in their own offices or other health care settings. UCHealth will share your information with these other
providers as described in this notice.
Your Rights
You have certain rights when it comes to your health information. This section explains your rights and some of our
responsibilities to help you. Several of these rights are fulfilled by our Health Information Management department. Visit:
https://www.uchealth.org/access-my-health-connection/medical-records-uchealth/ for further information.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we
have about you. We may require you to do this in writing. We will provide you with a copy of your health
information or a summary if you prefer. We may charge a reasonable, cost-based fee.
• We may deny your request for some of your health information. If we deny your request, we will inform you in
writing why we denied it, how you may have the denial reviewed in certain instances, and how you may file a
complaint regarding our decision.
Ask us to amend your medical record
You can ask us to amend health information about you that you think is incorrect or incomplete. We may deny your
request, but if we do, we will tell you why in writing.
Request confidential communications
You can ask us to contact you in a specific way (for example, ask us to contact you at work instead of your home) or to
send mail to a different address. We will accommodate all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for your treatment, our payment, or our operations.
We are not required to agree to your request, but if we don’t agree, we will tell you why in writing. Even if we agree
to your request, we may not follow it in an emergency situation. We may also change our decision in the future, but
if we do, we will tell you in writing. The change will only apply to your health information we create or receive after
we notify you of the change.
• If you pay for a service or health care item out-of-pocket and in full, you can ask us not to share that information
with your health insurer if it is for a payment or operations purpose. The request must be in writing and we will
approve your request unless we are required by law to share that information.

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Get a list of those with whom we have shared information
• You can ask for a list (accounting) of the times we have shared your health information for up to six years from the
date you ask, who we shared it with, when and why. We will include all the disclosures except for those about
treatment, payment, health care operations, and certain other disclosures, including any you asked us to make.
• We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another
one within 12 months.
Get a copy of this notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We
will provide you with a copy. You may print or view a copy of it by visiting: https://www.uchealth.org/privacy-policy.
Choose someone to act for you
We may disclose your information to a person named as your medical power of attorney or legal guardian. We will make
sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• To ask questions, express concerns, or file a complaint, contact our Privacy Officer at: Compliance Department,
2450 South Peoria Street, Aurora, Colorado 80014; by email at [email protected]; by phone at 855.824.6287.
• You can also file a privacy or civil rights complaint with the U.S. Department of Health and Human Services’
(DHHS) Office for Civil Rights (OCR), electronically through the OCR Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. DHHS, 200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201; 1-800-368-1019 or 1-800-537-7697 (TDD). Complaints to the
Office for Civil Rights must be filed within 180 days of when you learn of, or should have known about, the
violation.
• We will not retaliate against you for filing a complaint.
Your Choices
In certain situations, you can tell us your choices about what we share. If you have a clear preference for how we
share your information in the situations described below, let us know.
• Reminding you that you have an appointment for care.
• Sharing information with your family, close friends, or others involved in your care or payment for your care.
• Sharing information for disaster relief purposes with entities authorized to assist in disaster relief efforts.
• Including your information in a hospital directory. If you ask not to be listed in the directory, no information will be
provided to anyone asking about you. This may prevent visitors, mail, flowers, or other gifts from reaching you.
• Providing your religious affiliation to a member of the clergy, such as a priest, rabbi, or pastor.
• Contacting you for fundraising efforts. You can tell us not to contact you again by following the instructions we send
you when you are contacted.
• Sharing your health information through health information exchange (“HIE”). HIE organizations allow your health
information to be made available for treatment, payment and operations purposes with other health care providers
and health plans outside of UCHealth. HIEs maintain safeguards to protect your information.
If you are not able to or do not tell us your preferences (for example, if you are unconscious or do not indicate a
preference to us) we may share your information if we believe it is in your best interest. We may also share your
information when needed to lessen a serious and imminent threat to health or safety.
Our Uses and Disclosures
We are permitted to use or share your health information in the following ways:
To treat you
We can use your health information and share it with other professionals to provide, coordinate and manage your health
care and related services. For example, information about your visit may be provided to your primary care physician, with
payers for quality management purposes relating to your treatment, or with other providers or organizations to allow you
to receive care remotely or have virtual visits with our clinical staff.
For our operations
We can use and share your health information to run our organization, improve your care, and contact you when
necessary. For example, we may use your information to review your treatment, evaluate the performance of the staff
caring for you, or share with students being trained in the organization.
To bill for your services or other payment reasons
We can use and share your health information to bill and get payment from health plans or other entities. For example,
we give information about you to your health insurance plan so it will pay for your services. We may also query your

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insurance plan to determine the best, most effective drug to prescribe for you.
Future communications
We may communicate to you via newsletters, mailings, or other means regarding treatment options, health related
information, disease-management programs, wellness programs, research projects, or other community based initiatives
or activities in which we participate.
Business associates
Some of the services provided to you are performed on our behalf by outside vendors called Business Associates. We
will disclose your health information to our Business Associates to allow them to perform these services for us. For
example, we may contract with a copy service company to provide you copies of your health record. Business
Associates are required by federal law to safeguard your information.
How else can we use or share your health information?
We are allowed or required to share your information in ways that contribute to the public good such as public health and
research. We have to meet certain conditions in the law before we can share your information for those purposes.
Help with public health and safety issues. We can share health information about you for certain public health and
safety situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications;
reporting suspected abuse, neglect, or domestic violence; and preventing or reducing a serious threat to anyone’s health
or safety.
Research. We may use or disclose your health information for research studies but only when the researchers meet all
federal and state requirements to protect your privacy. You may also be contacted to participate in a research study.
Comply with the law. We will share information about you if state or federal laws require it, including with the federal
Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests. We can share health information about you with organ procurement,
banking or transplantation organizations for the purpose of facilitating organ, eye, or tissue donation and transplantation.
Coroners, medical examiners and funeral directors. We may share health information with a funeral director as
necessary to carry out their duties including arrangements after death, or with coroners and medical examiners to identify
the deceased, determine a cause of death, or as otherwise authorized by law.
Workers’ compensation, health oversight and government authorities. We can use or share health information
about you for workers’ compensation claims and with health oversight agencies for activities authorized by law and for
special government functions such as military, national security, and presidential protective services.
Law Enforcement. We may disclose health information to a law enforcement official for purposes such as to respond to
a search warrant, identify a suspect, fugitive or missing person, report a death believed to be a result of criminal conduct,
or report a crime committed on our property. We may also disclose health information to correctional institutions or law
enforcement officials under certain circumstances if you are in custody.
Lawsuits and legal actions. We may disclose your information in response to a valid court or administrative order. We
may also disclose your information in response to certain types of subpoenas, discovery requests, or other lawful
processes.
Our Responsibilities
We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or
share your information other than as described here unless you tell us in writing that we can. If you tell us we can, you
may change your mind at any time by notifying us in writing. We will notify you promptly if a breach occurs that may have
compromised the privacy or security of your health information.
Authorization Required. In the following cases, we won’t share your information unless you give us written permission:
• Marketing purposes, except if we talk with you in person or give you a promotional gift of little value from a
company we work with, like a pen or notebook.
• Sale of your information.
• Most sharing of psychotherapy notes, which are private notes maintained by your psychiatrist or psychologist.
Drug and Alcohol Treatment Records. We maintain records for patients treated in alcohol and drug abuse treatment
programs that are specifically protected by federal law and regulations. Certain UCHealth facilities that treat these
patients are required to comply with restrictions in addition to what is listed in this notice. A summary notice that includes
these restrictions will be provided to you at the time you are admitted to one of these programs.

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Revisions to this Notice. We reserve the right to change the terms of this Notice at any time. If we do, the changes will
apply to all information we have about you. The new Notice will be available upon request and on our website.
See hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html for more information on your rights and our
responsibilities.
Treating you fairly. University of Colorado Health and its associated facilities, like this one (together “UCHealth”)
complies with applicable Federal and state civil rights laws and does not or discriminate on the basis of race, color,
national origin, language, culture, ethnicity, age, religion, sex, mental or physical disability, sexual orientation, gender
expression, gender identity, veteran status, socioeconomic status, or any other characteristic prohibited by federal, state,
or local law. UCHealth provides:
Free aids and services to people with disabilities to communicate effectively with us, such as:
•
•

Qualified sign language interpreters
Written information in alternative formats (large print, audio, accessible electronic formats, and other
formats)
Free language services to people whose primary language is not English, such as:
•
•

Qualified interpreters
Information written in other languages

If you need any of these services, please let the information desk, your nurse, or your provider know. If you believe that
UCHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin,
age, disability, or sex, please contact the Patient Representative Office for your facility or region.
•
•
•
•
•
•
•
•

720.848.5277
970.495.7346
Hospital
970.495.7346
719.365.8581
970.875.2743
720.516.0124
720.718.1020
303.460.6028

University of Colorado Hospital
Northern Region: Greeley Medical Center, Medical Center of the Rockies, Poudre Valley
UCHealth Medical Group
Colorado Springs Region: Memorial Central, Memorial North, Pikes Peak Regional Hospital
Yampa Valley Medical Center
Highlands Ranch Hospital
Longs Peak Hospital
Broomfield Hospital

https://www.uchealth.org/about/nondiscrimination
You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint Portal, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Language Assistance
•
•
•
•

ATTENTION (English): Language assistance services, free of charge, are available to you.
ATENCIÓN (Spanish): si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
CHÚ Ý (Vietnamese): Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
注意(Chinese)：如果您使用繁體中文，您可以免費獲得語言援助服務。

•
•
•

주의(Korean): 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실
ВНИМАНИЕ (Russian): Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
����� (Amharic): ������ ��� ���� ��� ����� ���� ������
•
‫ﻣﻠﺣوظﺔ‬:(Arabic) ‫اﻟﻠﻐﺔ اذﻛر ﺗﺗﺣدث ﻛﻧت إذا‬، ‫ﺑﺎﻟﻣﺟﺎن ﻟك ﺗﺗواﻓر اﻟﻠﻐوﯾﺔ اﻟﻣﺳﺎﻋدة ﺧدﻣﺎت ﻓﺈن‬.
ACHTUNG (German): Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.
ATTENTION (French): Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement
ँ ाई भाषा सहायता सेवाह� िनःशुल्क उपलब्ध छन्
नेपाली(Nepali) :ध्यानाकषर्णः तपाईल

•
•
•

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•
•
•
•
•
•
•

PAUNAWA (Tagalog): Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad.
注意事項 (Japanese)：日本語を話される場合、無料の言語支援をご利用いただけます。
XIYYEEFFANNAA (Cushite/Oromo): Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama.
‫( ﺗوﺟﮭ‬Persian/Farsi): ‫ﺗوﺟﮫ‬: ‫ﮐﻧﯾد ﻣﯽ ﺻﺣﺑت ﻓﺎرﺳﯽ زﺑﺎن ﺑﮫ اﮔر‬، ‫زﺑﺎﻧﯽ رﺳﺎﻧﯽ ﯾﺎری ﺧدﻣﺎت‬، ‫راﯾﮕﺎن ﺑطور‬، ‫در‬
Dè ɖɛ nìà kɛ dyéɖé gbo (Kru/Bassa): Ɔ jǔ ké m̀ [Ɓàsɔ́ ɔ̀ -wùɖù-po-nyɔ̀ ] jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ̀ ɓɛ́ ìn m̀ gbo kpáa
Ntị (Ibo): Ọ bụrụ na asụ Ibo, asụsụ aka ọasụ n’efu.
AKIYESI (Yoruba): Bi o ba nsọ èdè Yorùbú ọfé ni iranlọwọ lori èdè wa fun yin o.

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Consent to Service

This Agreement applies to all hospitals, physician offices, clinics, and other facilities that are part of University of Colorado
Health ("UCHealth") on uchealth.org, including, but not limited to, UCHealth Broomfield Hospital, UCHealth Grandview
Hospital, Longs Peak Hospital, Medical Center of the Rockies, Poudre Valley Hospital, UCH-MHS (Memorial Hospital),
UCHealth Greeley Hospital, UCHealth Highlands Ranch Hospital, UCHealth Pikes Peak Regional Hospital, University of
Colorado Hospital Authority, UCHealth Yampa Valley Medical Center, UCHealth Medical Group, UCHealth Imaging
Services, LLC, UC Health Partners and UCHealth Ambulatory Surgery Centers (each a "Facility"), and including all health
care providers ("Providers") providing care at those Facilities, some of whom are employed by the University of Colorado.
On behalf of myself, my minor child, or if I am the healthcare decision maker for the patient named below, then for the
patient named below, I acknowledge and consent to the statements made in this form. Changes to this form are not
binding on UCHealth and/or any of its affiliated Facilities. This form (the "Agreement") applies for care and treatment now
and moving forward, until I sign another version of this Agreement or revoke this one.

Consent to Service
•

I consent to receive care at Facility from Facility, Providers, and their employees and contractors. I consent to
services the Providers consider reasonable and necessary for care and treatment including examinations, diagnostic
tests, laboratory services, routine hospital services, administration of medications, and other health care services. I
understand that I have the right to agree to or refuse care in accordance with the law.

•

If I am coming to the Facility to give birth of a child for whom I have the right to consent for care, by signing this
Agreement, I am also consenting to health care services for my newborn baby that my baby's Providers consider
reasonable and necessary, including examinations, diagnostic tests, laboratory services, routine hospital services,
administrative of medications, and other medical care.

fl
fl

I understand guarantees about health care cannot be made.
I understand that care and treatment may be provided by physicians, including fellows and residents, medical and
allied health students, physician assistants, nurses, and other health care providers. I understand that Facility is a
teaching resource for health care students.

•

I hereby consent and grant to Facility the right and authority to take photographs, images, audio recordings, and/or
video recordings (collectively "images or recordings") in connection with diagnosis and treatment. I agree that upon
creation of such images or recordings are owned by Facility, and may be used for quality improvement and education.
that recording or filming stop at any time. I acknowledge that Facility may
I understand that I have the right to
disclose these images as required or permitted by law.

•

I understand that certain services at Facility may be provided using remote telehealth technology. Such telehealth
services involve a health care provider who is not at the same location where I am when I am receiving the services,
and often includes the transmission of audio, video, images, and other data. I understand that telehealth technology is
not always available.

•

I authorize the Facility to take, retain, preserve and use for teaching purposes, or dispose of at its convenience all
specimens, tissues, parts or organs taken from my body during my care.

•

Emergency care: If I come to an emergency department seeking emergency care, I will receive a medical screening
examination to determine whether I have an emergency medical condition, and if so, care to stabilize my emergency
medical condition, regardless of ability to pay. I understand I may receive health care in an emergency even if I do not
sign this Agreement.

Personal Valuables
Neither UCHealth nor Facility is responsible for the loss or damage of personal belongings kept with a patient or visitor at
Facility. These may be things like money, clothing, jewelry, glasses, dentures, hearing aids, electronic devices,
documents, personal medical devices, or other valuable items.

Patient Rights and Responsibilities Acknowledgement
My signature on this form indicates I was offered a copy of the Patient Rights and Responsibilities.

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uchealtb

�

�

Consent to Service

Health Information Exchange
UCHealth participates in the electronic exchange of protected health information ("PHI") with other health care providers
and health insurance plans through approved health information exchange organizations. Through UCHealth's
participation, PHI may be accessed by other providers and health insurance plans or other permitted recipients of PHI, as
permitted by law, for treatment, payment, and health care operations purposes. These health information exchanges
maintain safeguards to protect the privacy of your PHI. You are able to opt-out of having your PHI accessed on these
exchanges. Please contact the Health Information Management department for information on how to opt-out.

Financial Agreement and Insurance Benefits
•

Out-Of-Network Providers. I understand that not all physicians or professionals providing services at the Facility are
employed or contracted by the Facility. Some of these providers may not have agreements with my insurance plans
and may be considered as "out-of-network" for my health plan. I understand I should ask my provider whether he or
she participates in the same insurance plans as the Facility. I understand that using these providers could result
in higher charges to my plan and could result in higher copayments or coinsurance that are my
responsibility. I understand my rights and payment obligations to out-of-network providers may be governed by state
law.

•

I understand that I am responsible for paying for health care at the rates charged by the Facility and any physicians or
other providers providing care, including any amount not paid by insurance.

•

I agree to pay the charges of the Facility for my care. A list of the non-discounted charges of the Facility, called a
chargemaster, is available on uchealth.org along with information about billing, payment, insurance, standard
charges, and financial assistance. The chargemaster is made a part of this Agreement and I have had an opportunity
to review that information and ask any questions.

•

I understand that insurance plans, government agencies, or other entities may have negotiated or discounted rates
other than those set forth in the chargemaster through agreements with the Facility or Providers. I understand if I am
not a beneficiary under those agreements, any negotiated or discounted rate is not applicable to services provided to
me and I am responsible for the full non-discounted rates set forth in the chargemaster.

•

I understand that my insurance or another source may help pay my bill, and may have negotiated some other charge
rate, but that the Facility has not made any representations about what I may be obligated to pay.

•

I understand the Facility, as a courtesy, may communicate with my insurance company about coverage. I
acknowledge that I have full responsibility to confirm whether my coverage is in-network or out-of-network as that may
impact the amount of payment by my insurance company. I understand I am responsible for payment based upon
chargemaster rates, not based on what my insurance tells the Facility about my coverage.

•

I authorize Facility to bill my insurance and request payments be made directly to the Facility. I understand that this
does not guarantee payment, and agree to pay the chargemaster rates for care that insurance does not pay. I assign
to Facility all rights to insurance payments or benefits to which I may be entitled for services provided to me by the
Facility. I will give the Facility information about my insurance or other health coverage and complete forms that may
be required to help pay for my health care, and that the Facility may make the decision to and actually bill me directly.

•

Some insurance plans work with health care providers as preferred providers. I understand that Facility and health
care providers at the Facility may not be a preferred provider for my plan. I agree to pay the full amount charged as
stated on the chargemaster rate if my insurance does not cover the health care services provided at the Facility at the
chargemaster rate.

•

Insurance and other payment sources sometimes require that I notify them to approve payment for health care. This
may include approval before getting a second opinion, before a test, or before coming to the hospital. My insurance or
other payment source may also require I let them know I was admitted to the hospital or treated for an emergency, or
that I am going to stay in the hospital longer than what was first expected. I understand communicating this to my
insurance or other payor insurance or payor is my responsibility.

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Consent

Service

e

If I have and am using my insurance, I agree to pay my part of the charge when I receive care or after my medical
screening examination and stabilization. My part of the charge may include, but is not limited to my deductible,
copayment, and coinsurance, payment for non-covered services or payment for any other services not paid by my
insurance carrier.

•

if I do not have insurance or am not using my insurance, payment in full or a deposit may be due at the time of service
other than a medical screening examination and care to stabilize any emergency medical condition.

•

I understand that before I am treated I can ask the Facility for the amounts generally charged rates for my care and
the Facility will provide a good faith estimate. I understand that Facility may not be able to provide this information to
me in an cases or in the case of an emergency. I understand that Facility cannot guarantee the accuracy of the
estimate, and that it does not account for unforeseen complications, additional tests or procedures, medical provider
bills, and non-hospital related charges, any of which may increase the ultimate charge of the services provided.

•

If I do not have insurance or I cannot pay the bill, I may qualify for a payment plan or for financial assistance if
approved by the Facility depending on my specific circumstances.

•

I understand that my payment is late if I do not pay all amounts due, or if I do not establish a payment plan with the
agreement of the Facility, within one hundred twenty (120) days after my first statement is mailed to me by the
Facility. I understand that if my account is sent to a collection agency or lawyer due to late payment or non-payment, I
will pay reasonable attorney fees and court costs. I understand that a $20.00 fee will be added to my bill if a check,
debit card or credit card payment I make is dishonored. I give up my right to trial by jury if I do not pay my bill in full on
time, and/or if I do not have sufficient funds in my account to cover my charge.

•

I understand that I may receive bills from health care professionals who provide services to or for me,
including but not limited to radiologists, surgical assistants, pathologists and anesthesiologists and
advanced practice providers, who may not be employees of Facility and may send a separate bill. I
understand that those professionals may assist in my care at the request of my provider, who has my
authorization to engage their services. It is up to me to pay for these services. If I have a payment plan with
Facility about paying my bills, I also need to make a separate payment plan for the services of these professionals. I
grant those providers access to this Agreement.

Consent to Telephone Calls, Text Messages, Voice Mail Messages, and Emails
By providing a telephone number, whether cellular or otherwise, to Facility now or at a later time, I consent to receiving
telephone calls and/or text messages, or other communications using live, artificial, or prerecorded voices, automatic
telephone dialing systems, or any other computer-aided technologies from Facility and its Affiliates. Affiliates includes my
health care providers, business associates, agents, contractors, vendors, assigns, successors, servicers, and collection
agencies. I certify, warrant and represent that I am authorized to receive calls at any of the telephone numbers have
provided. The text messages and phone calls may be related to any purpose, including related to my account and my
health care, like appointment reminders or offers for additional services. I understand that standard text messaging rates
may apply. I agree that Facility and my health care providers may share with Affiliates any telephone number(s) I provide
to Facility so that the Affiliate(s) may make the calls or texts on behalf of Facility or my health care provider. I understand
that I may revoke my consent to receive such calls and texts at any time. The callers may leave the name of the company
making the call or reference whom the caller is representing.
By providing an email address, I give Facility and Affiliates permission to contact me by email about my or my
dependents' health care or costs related to health care using any email address I provide to Facility or its Affiliates.
Affiliates may use any email address or phone number I give Facility or that they may obtain for me.

Governmental Immunity Notice
Many health care providers at Facility are considered public employees under the Colorado Governmental Immunity Act
(CGIA), and some hospitals and clinics are considered public entities under the CGIA. The CGIA limits the amount of
damages recoverable from public employees and entities, requires a formal notice of claim, and places a 182-day time
limit on the period for filing such a notice of claim.

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Consent to Service

Non�Discrimi nation
University of Colorado Health and its associated facilities, like this one (together "UCHealth") complies with applicable
Federal and state civil rights laws and does not or discriminate on the basis of race, color, national origin, language,
culture, ethnicity, age, religion, sex, mental or physical disability, sexual orientation, gender expression, gender identity,
veteran status, socioeconomic status, or any other characteristic prohibited by federal, state, or local law. UCHealth
provides:
•

Free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters.
-

•

Written information in alternative formats (large print, audio, accessible electronic formats, and other formats).

Free language services to people whose primary language is not English, such as:
Qualified interpreters.
-

Information written in other languages.

If you need any of these services, please let the information desk, your nurse, or your provider know. If you
believe that UCHealth has failed to provide these services or discriminated in another way on the basis of race, color,
national origin, age, disability, or sex, please contact the Patient Representative Office for your region:
720.848.5277 in Metro Denver
970.496.7346 in Northern Colorado
719.365.5621 in Colorado Springs
303.460.6028 in Longmont and Firestone
You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint Portal, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1.800.368.1019, 800.537.7697 (TDD)

Arctic PQ Information

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