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Before receiving health care services from ²ÊÃñ±¦µä, patients will be asked to agree to the following.

Consent for Treatment

• I voluntarily consent to the provision of health care services including, but not limited to, diagnostic tests, medications, injections, and medical treatment that may be considered necessary by my Medical Services and/or Counseling and Psychiatric Services (CAPS) health care provider(s) or allied health professional(s).
• I understand that it is my right to discuss any proposed service with my health care provider(s) and that I have the right to refuse care, treatment, and services in accordance with law and regulation.
• I understand that the practice of medicine is not an exact science, and I acknowledge that no promises or guarantees have been made to me regarding the efficacy of treatment or services rendered to me.
• I understand that Medical Services and/or CAPS may serve as a training site for health care professionals, students, interns, and residents and that health care services may be rendered by these individuals under supervision. I further understand that these individuals will always be clearly identified and that I have the right to refuse their involvement in my care.
• I understand that the content of phone calls, voice mail messages, and email/secure messaging will be incorporated into my health record.
• I understand that I, or my designated representative, have the right to inspect my health records at reasonable times and upon reasonable notice as permitted by law.
• I understand that my health information may be disclosed when required to do so by federal, state, or local law.

PAYMENT AGREEMENT, BILLING/INSURANCE:

• I assume full responsibility for and agree to pay or have paid all costs, charges, co-payments, and expenses for services, facilities, medication, and any other items or care supplied to me by the date stated on the bill. I understand that account balance reminders may be e-mailed to me.
• I understand that billing of insurance or other benefits is a service only and is not a guarantee of payment. Health and Wellness Services (HWS) will submit a claim to your insurance carrier regardless of their contract status, except for Medicaid and Medicare. HWS will accept the terms of your insurance plan as indicated on the Explanation of Benefits (EOB).
• I understand that I am financially responsible to HWS for:
  1. charges not paid for by insurance or any third party payor, unless otherwise prohibited by state or federal regulations and
  2. any costs and fees, including attorney fees, in the event that HWS brings any action because of any failure by me or someone on my behalf to pay my bills in full.
• I understand that I am responsible for obtaining all pre-authorizations necessary to comply with any insurance or medical/hospital plan upon which I am relying for coverage. I authorize and request any and all third parties responsible for any portion of my bill to make payment directly to HWS.
• I authorize the release of my health records to my insurance or any other insurance carrier for claims processing. I will promptly furnish, complete and sign any forms that may be necessary to obtain reimbursement from Payer to HWS for services rendered. I understand that if I fail to provide my insurance information within 30 days from the date of service, I may be liable for the charges incurred. If I am entitled to any benefits from any insurance policy or public entitlement insuring me or any other party liable to me, such benefits are hereby assigned to HWS for application to my bill.
• I understand it is my responsibility to validate my health plan coverage and benefits prior to receiving services. I understand I will be financially responsible for the cost of all services if my provider is out-of-network or my insurance plan is non-participating with HWS.

LABORATORY:

• I understand that specialized lab work may be sent to an outside reference lab and any financial charges from outside labs are separate and distinct from my HWS bill. It is my responsibility to work with the laboratory staff to determine if any of my specimens will be sent to an outside reference lab. The cost of the lab sent to an outside lab will be billed directly to me by the outside reference facility and I assume financial responsibility for any charges.

OTHER:

• I understand that copies of the General Agreement for Health Care Services, the Patient Rights and Responsibilities, and the Notice of Privacy Practices are available upon request.
• I understand that a chaperone shall be provided upon request by either myself/parent/guardian or my health care provider(s) for any part or all of an examination or procedure.
• I understand that if I have concerns about safety, care, or services, I should speak to the department manager.
• I understand that my health record will be destroyed in compliance with the law.
• I understand that I can revoke any part of this consent or authorization at any time in writing; such revocation may affect HWS ability to provide me with health care services. This agreement is valid for all services performed by staff of Medical Services and CAPS during the academic year in which it was signed.