UCF No Show Policy Effective 11/21/2018
Patients 18 years old and up, please answer the following questions:
* Primary Legal Guardian is the court-appointed person to make healthcare decisions in place of the patient. Primary Caregiver is the person responsible for providing day-to-day care for the patient. Medical Power of Attorney (Healthcare Proxy) is the patient-appointed person to make healthcare decisions in place of the patient. The Delegated Individual is the patient-appointed person to communicate with about my healthcare, which may include information about my medical diagnosis, eligibility status and appointments. Appropriate documentation must be provided.
POLICY HOLDER INFORMATION
INSURED'S EMPLOYER INFORMATION
Patient Information Documents
My signature below acknowledges I have been provided with a Patient Information Package, which includes a:
Consent to Treatment, Testing, and Procedures
I consent to all tests, treatments and procedures ordered by UCF providers including, without limitation, testing for communicable or blood-borne diseases such as sexually transmitted diseases, Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), and Hepatitis. As part of my testing and treatment, I may receive disease- specific prevention, education, and risk-reduction services. I understand that UCF is required by state law to report information to the City of Houston Department of Health & Human Services for persons who test positive for certain
diseases (known as “reportable diseases”) including, but not limited to, tuberculosis, HIV/AIDS, and syphilis. If I test positive for a reportable disease, I understand that I will be contacted by a state-authorized Disease Intervention Specialist to promote successful treatment and notification of any sex partners, if applicable, who may be at risk for the disease.
I also understand that if a UCF health care worker is accidentally exposed to my blood or body fluids, (for example by a needlestick), UCF can draw and/or use blood drawn from me for testing purposes.
I understand that if I qualify for services through a grant funded program such as Family Planning or the Health and Human Services Commission Healthy Texas Women's/Plus programs these resources are payers of last resort. As payers of last resort, grant-funded programs may not continue my eligibility if I currently or in the future have Medicare, Medicaid and/or third party insurance coverage. Therefore, I agree to immediately report any changes in my financial status and/or insurance coverage to the Eligibility Specialist. If I fail to appropriately report changes in my financial status and/or insurance coverage, and if those changes result in my ineligibility for services under a grant funded program, I understand that I am fully responsible for the cost of services delivered by UCF.
By signing below, if I am eligible for Medicaid, Medicare and/or third-party insurance coverage while a client of UCF,
I authorize UCF to furnish to Medicaid, Medicare and/or third-party insurance coverage all of the necessary information, including my HIV status, to process my claim. I also hereby assign to UCF all payments received from Medicaid, Medicare and/or a third-party insurer for services and treatments provided to me by UCF. I understand that I may be responsible for paying any required co-payments prior to being seen by a health care practitioner. I also understand that I am responsible for the cost of services and treatments delivered to me that are not covered by my insurance.
UCF participates in research studies, which can involve proven or experimental treatments. By signing below, I authorize UCF staff to review my information to determine if I qualify to participate in current or future studies. If I qualify, I will be notified and provided with the opportunity to accept or decline research participation. My signature below does not mean
I agree to be in a research study.
E-Prescriptions, E-Rx or Electronic Prescriptions, are computer-generated prescriptions created by your provider and sent directly to your pharmacy. UCF participates in E-prescribing because we care about your health and well-being and
E-prescribing has multiple benefits. By consenting, UCF can also access a history of my current and past prescriptions. This critical information assists UCF in confirming the safety of my prescriptions and minimizing dangerous interactions with my other medications.
I understand that my email address and other contact information that I have provided will be used by UCF for various various purposes including, but not limited to, appointment reminders, prescription medication refill reminders, and registration for UCF's patient portal. UCF's secure patient portal allows patients to communicate with their health care providers and access some information in their medical records such as medication lists, certain laboratory results,
and immunization records, however, these features may change from time to time. I understand that my email address address will be used by UCF to create a secure portal account for me, but that I will be required to establish my login information in order to access the portal.
Greater Houston Healthconnect
UCF may participate in Healthconnect, a non-profit organization that provides a secure electronic network for Healthconnect participants. A list of current Healthconnect participants is available at www.ghhconnect.org. UCF's participation with theirs in Healthconnect, such as labs, pharmacies, radiology centers, doctors’ offices, hospitals, and health insurers, permits UCF to access, and utilize in providing care to you, any available electronic health information related to you. All Healthconnect participants must protect your privacy in accordance with state and federal laws. Your treatment and eligibility for benefits will not be affected. By my signature below, I agree that Healthconnect and its current and future participants, including UCF, may use and disclose my protected health information electronically for the limited purposes
of treatment, payment and health care operations. I understand that Healthconnect may connect to other health information exchanges in Texas and across the country that also must protect my protected health information in accordance with state and federal laws, and I authorize Healthconnect to share my information with those exchanges for the same limited purposes of treatment, payment and health care operations. This authorization remains in effect unless and until I revoke it. I understand that I can revoke this authorization at any time by giving written notice to any healthcare provider who participates in Healthconnect and my revocation will be effective within three (3) days. I also understand that revoking
this authorization does not affect information previously shared when my authorization was in effect.
Important Information You Need to Know about Telehealth/Telemedicine at UCF
Limitations of Telemedicine/Telehealth
As a UCF patient receiving services via telemedicine/telehealth, your provider is required to provide notice (an explanation) regarding telemedicine/telehealth services, including the risks and benefits of being treated via telemedicine/ telehealth, how to receive follow-up care or assistance in the event of an adverse reaction to the treatment or in the event of an inability to communicate as a result of a technological or equipment failure.
Necessity of In-Person Evaluation
As a UCF patient receiving services via telemedicine/telehealth, your provider is required to inform you before the conclusion of the encounter, if he or she is unable to provide all pertinent clinical information that a health care provider exercising ordinary skill and care would deem reasonably necessary for the practice of medicine or health services at an acceptable level of safety and quality in the context of that particular medical encounter. If that occurs, your provider is required to advise you to obtain additional medical evaluation reasonably able to meet your needs.
Rights and Responsibilities, Recording Telemedicine Appointments
I understand that by agreeing to participate in UCF’s telemedicine/telehealth services, I will not audio and/or audio/video record UCF workforce members without their express permission obtained in advance of any recording. A violation of this recording limitation may result in UCF requesting that I destroy the recording, including any postings of the materials that have been shared and may also result in UCF discontinuing telemedicine/telehealth services to me.
Complaints to the Board
As a UCF patient receiving services, if you wish to file a grievance or complaint with the Texas Board of Medicine or UCF's Risk Manager, please contact UCF at compliance@myUCF.org, 346-874-8622, or via mail at 8785 West Bellfort St Houston, TX 77031. You will not be penalized for filing a complaint.
Terms of Consent
I understand my consent is necessary for UCF to offer services to me and that some items may not apply to my current situation. I also understand that, in order to provide comprehensive care during this and future visits, and to evaluate my eligibility for programs, my signature below indicating my agreement to this document in its entirety, is required. By signing this form, I acknowledge and agree to the terms, information and obligations contained in this document. I am giving this consent of my own free will. I have had the opportunity to read and ask any questions about the information in this packet, specifically including, but not limited to, the financial obligations provisions and assignment of benefit provisions.
I acknowledge that I either have no questions or that my questions have been answered to my satisfaction in a language
I understand. I sign this document freely and agree to abide by its terms. I understand that this document remains in effect until I revoke my consent, at any time, in writing. I also understand that revoking this authorization does not affect any actions previously taken based on this consent By signing this form, I attest that all the statements I have made, including my answers to all questions, are true and correct to the best of my knowledge and belief. I agree to give the UCF eligibility staff any information necessary to confirm statements about my eligibility. I understand that giving false information could result in eligibility disqualification and a possible repayment obligation. I also agree to inform the eligibility staff of my income or number of people in my family change.