- I hereby give consent to University Health (UH), UH providers, University Health Physicians (UHP) and their employees, agents, designees and professional consultants to provide me or the individual for whom I am legally responsible all routine medical care, including routine diagnostic medical, dental and psychiatric treatment deemed medically necessary or desirable.
- I have been informed that UH is an academic, teaching facility. I am aware of and consent to receive treatment by physicians in training and medical, dental, nursing and other students who are deemed appropriate.
- I am aware that the practice of medicine, dentistry and psychiatry is not an exact science and I have been provided no guarantees as to the result of examinations, treatment or surgeries.
- I understand that my clinical interactions will be conducted via telehealth services pursuant to the UH Medical Staff Bylaws. The telehealth vendor will collect data that will be available only to UH and the vendor. The vendor will only share that data for purposes of sending me visit notification information, or to comply with applicable laws and regulations, or other lawful requests for information.
- I understand that if I disconnect from the telehealth service without completing my consultation or visit, I am responsible for any outcome that occurs.
FINANCIAL RESPONSIBILITY/ASSIGNMENT OF INSURANCE/SURVEYS:
- Assignment of Insurance Benefits: I hereby assign all my interest and rights to all insurance benefits, otherwise payable to me from any policy of insurance covering my period of treatment, issued in my name or on my behalf, to UH and any providers I see while receiving treatment.
- Personal Financial Responsibility: I am personally responsible for all UH fees and provider fees not paid by any third party on my behalf.
- Financial Cooperation: I have been informed and agree that I will cooperate with UH in submitting my application for any governmentally subsidized program that may provide partial or total reimbursement for certain services. If such program funds are available, I hereby authorize those funds be paid directly to UH and/or my providers on my behalf and for my account, provided that no other third parties have paid such amounts.
- Medication Assistance Program: I understand that in some cases, the hospital is able to obtain reimbursement for some of my medications from companies that manufacture them. When this occurs, the cost of the medication is removed from the charges on my hospital stay. Most of these programs require my signature on the applications forms. So that I do not have to sign this application for each medication, I agree to allow Pharmacy Health Solutions (PHS) representative to sign these forms on your behalf.
I appoint PHS to carry out in my name, the application forms required for PHS to obtain replacement of my medications from pharmaceutical manufacturers. This document will be in full force from the date signed.
- I consent to be contacted by telephone (including a cell phone number) regarding any matter related to my account or my experience at UH by UH or any entity to which UH uses for these services. I also consent to the use of any updated or additional contact information that I may provide by UH or any entity to which UH hires for these purposes. I consent to the use of technology, including an automatic telephone dialing system and/or artificial prerecorded voice message, in contacting me regarding any matter related to my account or my experience at UH. I understand these calls or text messages are for debt collection purposes or patient reviews and not advertisements or for telemarketing purposes. I understand that I can revoke this consent at any time.
- Release of Non-Identifiable Information: I consent to UH's disclosure of any non-identifiable portion of my medical record for research or education purposes.
- I agree that it is my responsibility to treat other patients, visitors and staff with respect. I understand that disrespectful behavior will not be tolerated and may result in the disconnection of my consultation or visit.