Consent for Treatment and Acknowledgements
To become a patient and receive treatment, we need your consent to provide care. We also need you to acknowledge that we have provided you with certain important information and documents. If you have any questions about any of this information, please do not hesitate to ask a member of our staff. By signing, you are indicating that you understand the information, have been given a chance to ask questions, and are giving your consent.
General Consent to Treat
I voluntarily agree to receive services from Universal Community Health Center (UCHC), and authorize the providers of Universal to provide such care, treatment, or services as are considered necessary and advisable for me. I understand that I should participate in the planning for my care and that I have a right to refuse interventions, treatment, care, services or medications at any time to the extent the law allows. I understand that the care I will receive may include tests, injections, and other medications, etc. that are based on established medical criteria, but not free of risk.
Notice of Privacy Practices
I understand that, under the Health Insurance Portability and Accountability Act of 1998 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
Conduct, plan, and direct my treatment.
Obtain payment from third-party payers.
Conduct normal healthcare operations.
I acknowledge that I have read Universal's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Universal has the right to change its Notice of Privacy Practices at times and that I may request a current copy of the Notice of Privacy Practices at any time.
Health Information Exchange
I understand that Universal participates in certain health information exchanges with other health centers and hospitals located in Los Angeles area. Your health information may be shared with these exchanges to provide faster access, better coordination of care, and to assist providers and public health officials in making more informed decisions. Please notify Universal if you wish to "opt-out" and disable access to your health information, except to the extent that disclosure of such information is permitted or mandated by law.
Release of Information for Billing and Consent to Reimburse
I know that Universal needs to send parts of my personal health information to organizations that help pay for my care, such as insurance payers or organizations that grant money to Universal. I allow Universal to release the relevant parts of my records so that my care can be paid for. If I do not feel comfortable with this, then I understand that I can request a higher level of privacy protection than is afforded to me under the Health Insurance Portability and Accountability Act (HIPAA).
Acknowledgment of Duty to Reimburse Universal for Health Care Services
I understand that Universal offers a Sliding Fee Scale of discounted or free health care items and services to individuals who are deemed unable to pay based on their level of income. To become eligible for Universal's Sliding Fee Scale of discounted services, I will need to provide Universal staff with documents establishing that I meet income eligibility requirements which include proof of income and family size. If I do not provide the required documents to Universal, I am responsible for paying my fees for medical, behavioral health, or dental services received at Universal in full at the time of service.
By signing my name below, I am acknowledging that I have read and understand each of the separate paragraphs set forth above.