Parent/Guardian UAF SHCC Consent to Treat a Minor

Welcome to the UAF Student Health and Counseling Center (SHCC). Our professionally trained staff provides services in the areas of medical care, counseling, health education, and student health insurance.

Our aim is to provide your child/student with excellent professional care.  If you have questions about the services your child/student receives or have any problems with services at SHCC, please discuss these matters with your child/student's service provider or the Director of SHCC.

The UAF Health Center Fee your child/student paid as part of their university fees supports SHCC and covers the cost of most medical and counseling services we offer. The health center offers all healthcare services with a fee of $25 per visit.  There are modest charges for some services such as laboratory, supplies, medications, and extended counseling. When there are charges, payment is due at the time of service. Any charges left unpaid will be forwarded to the UAF Bursar’s Office at the beginning of each week along with a description of the nature of the charge (e.g. lab work, medication, medical appt. or counseling).  Once an unpaid charge is sent to the UAF Bursar’s Office, the Student Health and Counseling Center can no longer accept payment for that charge.  The Bursar’s Office will send a bill and payment must be made to the Bursar’s Office.  Grade reports and registration may be delayed if bills remain unpaid per Bursar policies.

If your student misses an appointment without canceling or rescheduling prior to their appointment time, they will be charged a $25.00 “no-show” fee per missed appointment.  This charge will be applied to the student account and can be paid through UA online or the Bursar’s office. If they check-in more than 15 minutes late for their appointment, it will be considered a “no-show”, and the appointment will be canceled with the option to be rescheduled. 

This authorization will expire in one year or upon the 18th birthday of the listed minor.

Parent/Guardian UAF SHCC Acknowledgement of Privacy Practices

Please review our Notice of Privacy Practices carefully.  You will be giving us information about your child/student and their health and personal needs and we want you to understand how we record their personal health information, how we assure the security of that information, and--most importantly--how we control the use of that information.  We abide by the federal laws, state laws, and professional ethical standards that control the way we handle your child/student's personal health information.  There are circumstances where we will release protected health information you or your child/student provides us without your authorization or knowledge and these situations and circumstances are explained in detail in our Notice of Privacy Practices.

We are required by federal law to ask you to sign this form acknowledging that we have given you a chance to review our Notice of Privacy Practices and that we have offered you a copy of the Notice.  If for any reason you do not want to sign this form, one of our staff will sign it and will indicate that you were offered our Notice of Privacy Practices and that you did not want to sign this form. We also publish our Notice of Privacy Practices on our website at www.uaf.edu/chc and there is a copy of the Notice of Privacy Practices posted on a publicly accessible bulletin board here at the Center.