A. CONSENT TO MEDICAL TREATMENT
I consent to the medical treatments or procedures, examinations, medications, injections, laboratory
and/or diagnostic procedures, and clinic services rendered to me under the general and special
instructions of the UCSF Student Health and Counseling Services (SHCS) primary care providers or other
health care professionals assisting in my care.
I understand I have the right to receive complete information regarding any treatment, procedure or test,
and that I have a right to refuse any treatment procedure or test, and to be informed of the medical
consequences of my actions or decisions.
B. USE OF MEDICAL INFORMATION
UCSF SHCS will obtain my written authorization to release information about my medical treatment
except in those circumstances where SHCS is permitted or required by law to release information.
Additionally, I understand that if I am diagnosed with a reportable disease in California, including but not
limited to HIV, tuberculosis, and cancer, my provider is required by law to report my diagnosis to the State
Department of Health Services or the Center for Disease Control and Prevention.
Instances in which SHCS may release my information:
i. As Required By Law: We will disclose Health Information about you when required to do so by
federal or state law.
ii. To Parties in Connection with an Emergency: We may use and disclose Health Information about
you to appropriate parties in connection with an emergency, if these parties’ knowledge of the
information is necessary to protect the health or safety of the student or other individuals.
iii. Public Health Disclosures: We may disclose Health Information about you for public health
activities such as:
- preventing or controlling disease (such as cancer and tuberculosis), injury or disability;
- reporting vital events such as births and deaths;
- reporting child abuse or neglect;
- reporting adverse events or surveillance related to food, medications or defects or problems with
products;
- notifying persons of recalls, repairs or replacements of products they may be using;
- notifying a person who may have been exposed to a disease or may be at risk of contracting or
spreading a disease or condition;
iv. Health Oversight Activities: We may disclose Health Information to governmental, licensing,
auditing, and accrediting agencies as authorized or required by law.
C. FINANCIAL AGREEMENT
Authorization to Bill: I authorize UCSF SHCS to bill my health insurance plan for any services and
treatments provided to me that incur a charge. I accept responsibility for payment for all services not
covered by my insurance. All students, especially those not enrolled in UC SHIP, should inquire about
the cost of vaccines and other services for which they may incur a charge if provided by SHCS.
This “Authorization to Bill” may be revoked by me at any time by sending a secure message through the
MyHealthRecord portal (submit a General Administrative Question). The authorization is valid until
revoked by sending the secure message.
Referrals: A referral from an SHCS provider does not guarantee payment for those services. You must
follow the stipulations of your health insurance plan to the extent applicable, including obtaining referrals
from network providers, if required. Only allowable benefits will be covered by your health insurance
plan.
D. COMMUNICATIONS REGARDING MY CARE
SHCS maintains a secure patient portal that allows currently registered students to access the following
online services:
- Make, cancel and/or reschedule appointments
- Communicate with providers of care and other clinical staff via secure messaging
- Print/view Immunizations and Referrals on file in your record
- Print/view the results of lab testing ordered by SHCS via secure messaging
Secure messaging should not be used for urgent issues. Secure messaging must not be used for results
of testing relating to HIV. I hereby agree to secure message communications with UCSF SHCS and/or
my SHCS provider(s) in accordance with these guidelines.
I agree that UCSF SHCS may leave confidential voice messages for me on my home and/or cell
telephone numbers.
E. OPTIONS FOR REPORTING SEXUAL MISCONDUCT
Your safety and privacy are of the utmost importance. The SHCS website homepage
(studenthealth.ucsf.edu) has a link to the various ways you may report sexual harassment or misconduct,
including in the clinical setting.
I certify that I have read the foregoing and been informed that a copy of this text is available from
the UCSF SHCS front desk staff or on the Student Health and Counseling website. I certify I am
the patient or the patient’s parent or legal guardian, or am otherwise duly authorized by the
patient to sign by acknowledging this document and accept its terms on the patient’s behalf.