Consent to Treat and Health Care Agreement - University of Houston
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Consent to Treat and Health Care Agreement

Consent to Treat: The UH Student Health Center is an integrated healthcare facility providing medical and mental health services. Acknowledgment of the Consent to Treat and Telemedicine Informed Consent is obtained electronically through the Healthy Coog Patient Portal.

Medical Services: Permission is hereby granted to the UH Student Health Center to administer recommended immunizations upon request or to carry out indicated medical (i.e. labs, urine drug screening, etc.) or surgical tests or treatment. Permission is also granted to the UH Student Health Center to refer me to another licensed physician for the necessary continuation of care.
Mental Health Services: Permission is hereby granted to the UH Student Health Center attending psychiatrists to render mental health evaluation and/or treatment. I also authorize such treatment or diagnostic studies (i.e. labs, urine drug screening, etc.) as, in the judgment of mental health staff, may reasonably be necessary to preserve and protect my health and wellbeing. An additional consent form for mental health services will be required.
Telemedicine: The University of Houston Student Health Center will provide services through limited Telemedicine during mandatory health-related university closures or when determined to be necessary by a Student Health Center provider. This document covers your rights, risks, and benefits associated with receiving services via telemedicine

Confidentiality: Medical information is not released without the patient’s consent except as required by law.

Financial Responsibility: Insurance is not necessary to receive care at the UH Student Health Center.

If you do have the UH endorsed Student Health Insurance, the UH Student Health Center will submit your eligible charges and you will be responsible for the co-pay cost only (if applicable). I hereby consent to the release of my medical records for the purpose of Student Health Insurance Billing (if applicable).

If you have private insurance, you will be responsible for payment at the time of service. The UH Student Health Center can provide you with a statement suitable for submission to your insurance company for reimbursement. The clinic cannot submit it for you. You will be asked to pay the UH Student Health Center for the visit and charges on the day of service.

Payment is required when services are rendered. Visa and MasterCard are acceptable forms of payment.

Payment may be transferred to your University Account. If you wish to encumber your university account with your UH Student Health Center charges, please let our Patient Services Desk staff know when you check out.

Athletics Billing with Authorization: The UH Student Health Center will bill Athletics upon receipt of acceptable authorization from the University of Houston Sports Medicine Department. I understand that I am fully responsible for all charges regardless of my department’s authorization. I hereby consent to a release of my medical records to the University of Houston Sports Medicine Staff for the purpose of billing and/or determination of sports eligibility.

UH Department Billing with Authorization: The UH Student Health Center will bill a UH Department upon receipt of acceptable authorization. I understand that I am fully responsible for all charges regardless of my department’s authorization. I hereby consent to the release of my medical records for the purpose of UH departmental billing (if applicable).

*The UH Student Health Center does not treat Worker’s Compensations cases.

Missed Appointments: No Shows and Late Cancelations penalize other patients who have to wait for an appointment with one of our clinics. It could even force a patient to seek care outside the UH Student Health Center costing them more than our services in‐house. Missed appointments will be charged a "no show/late cancelation fee".

We request that you plan to arrive at the Student Health Center at least 15 minutes prior to your scheduled appointment to allow enough time to complete the check-in process.

If you arrive after your scheduled appointment time, you will be asked to reschedule your appointment. A No-Show fee will be posted to your university account if you fail to arrive at your scheduled appointment without appropriate notice.

*Please take into account the time to travel to our destination which includes traffic and finding a parking space as well as check-in process so as not to risk a late arrival or no show.

Telemedicine Informed Consent

Telemedicine involves the use of electronic communications for the evaluation and treatment of non-emergent healthcare needs. Telemedicine may on occasion involve consultation with a specialist or other healthcare provider and the sharing of relevant medical information for the purpose of improving patient care.

Shared information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

  • Patient medical records
  • Medical images
  • Live two-way audio and video

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
  • Access to medical care when face-to-face visits are not possible
  • Efficient medical evaluation and management
  • Improved coordination of care
Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider;
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors

Patient Consent to the Use of Telemedicine:

  • I have read and understand the information provided above regarding telemedicine and will discuss it with a UH Student Health Center provider or representative as may be designated if I have any questions.
  • I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
  • I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my right at any time by contacting the Student Health Center at 713-743-5151.
  • I confirm that I am located in the state of Texas and will be in Texas during my telemedicine visit(s).
  • I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
  • I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
  • I understand that a variety of alternative methods of medical care may be available to me and that I may choose one or more of these at any time.
  • I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
  • I understand that it is my duty to inform the UH Student Health Center of electronic interactions regarding my care that I may have with other healthcare providers.
  • I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
  • I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
  • I understand my financial responsibility.
  • I understand that if any labs or testing are ordered, the services may be provided by a healthcare facility outside of the Student Health Center and I will be responsible for the cost of these services.
  • I understand that this document will become a part of my medical record.

By consent to treatment by telemedicine, I attest that:

  1. I have personally read this form (or had it explained to me) and fully understand and agree to its contents;
  2. I have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and
  3. I am located in the state of Texas and will be in Texas during my telemedicine visit.