Knoxville Area Project Access: Patient Responsibilities

	Home Eligibility Requirements Application Form Where to Register Patient Responsibilities

Knoxville Area Project Access
Patient Responsibilities

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Click on link below to download a PDF of the Patient Responsibilities Form. This version can be printed out, signed and returned to the KAPA Offices. Return information is printed on the form.

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(Adobe PDF File)

Program Overview:
Doctors, hospitals and many others have donated their services to help you get well and stay well. Please note that the availability of services depends on volunteer physicians and could end due to lack of volunteer services. Your responsibilities, the assistance available and other conditions may change at any time. By signing this form you agree to comply with the Patient Responsibilities below, and you authorize Knoxville Area Project Access (KAPA) to verify what you have reported during the application process. Patients who anticipate legal action regarding an injury or illness are not eligible for help through KAPA. We reserve the right to require that you pay for any assistance you may receive based on inaccurate information provided by you. You may also receive some bills, for which you are responsible, should you need services not currently being donated for by the KAPA program.

You agree that you:

Will schedule your KAPA appointments through the KAPA office. Referrals to a specialist will be made based on your primary care physician's recommendations.
Will follow your treatment plan, for example: get prescribed medications and take as directed.
Will promptly supply any information, which may be requested by the program, within the timeframe requested.
Will allow all information regarding your participation in this program to be shared with other individuals, organizations and agencies solely at the discretion of KAPA, in accordance with state and federal laws.
Will immediately contact KAPA if your income changes or if you become covered by Medicare, TennCare, private insurance, or any other health insurance/medical benefits.
Will apply for TennCare or other assistance programs if you are eligible.
Will authorize the State Department of Human Services to share information regarding your eligibility for TennCare and other programs with KAPA staff and medical providers.
Will contact KAPA immediately with any changes in your address or phone number.

You further agree to:

Keep each doctor's appointment. (If you miss your appointment without notifying the doctor's office at least 24 hours before your appointment, you may be disenrolled from the program.)
Present a photo I.D. each time you see a KAPA doctor.
Call your primary care physician or KAPA if you need to be seen anywhere else for treatment.
Limit your emergency room visits to true emergencies. For most problems, such as a sore throat, allergies, etc., you can get faster and less expensive treatment through your primary care physician. KAPA patients who repeatedly go to the emergency room without a genuine emergency, may be disenrolled from KAPA and may be responsible for emergency room charges.