General Consent and Acknowledgement

Consent for Treatment 

I hereby authorize the physicians and mid-level providers of United Community Health Center to administer medications, perform examination and diagnostic procedures. This consent will remain in effect until such time I notify United Community Health Center in writing of termination of said consent. 

Statement of Financial Responsibility 

I hereby authorize United Community Health Center to furnish information necessary to the payor(s) concerning each illness/accident for which I seek treatment and hereby irrevocably assign United Community Health Center all payments for medical services rendered. I understand that I am financially responsible for all charges whether or not covered by my third party payer(s). 

UCHC is a non-profit organization whose mission is to serve the health care needs of those in our communities. We depend on all patients to fulfill their payment obligations to continue providing dependable, quality health care to you and other patients. UCHC has a Refusal to Pay policy, this policy will go into effect after 60 days past due balance has not been addressed or if patient voices that they will refuse to pay. UCHC does offer payment plans if needed. If no efforts have been made by the patient or guardian to pay on balances over 60 days, this is deemed refusal to pay and UCHC will explore possible discharge of the patient from UCHC. 

All patient insurance information must be provided to UCHC and kept up to date. Coordination of Benefits (COB) should be set up with your insurance before you are seen to ensure all claims will be paid and not denied for Coordination of Benefits. This is the patient's responsibility. If claim is denied for Coordination of Benefits, the patient may be responsible for the cost of the visit. 

Good Faith Estimate (GFE) 

You have the right to request a Good Faith Estimate (GFE) for the cost of your medical care if you are uninsured or paying out‑of‑pocket. A GFE shows the expected charges for your visit, including any related tests or services. You can request one before scheduling or when you schedule care. If your bill is $400+ higher than the estimate, you can dispute the charge through a federal process. To request your Good Faith Estimate, contact our office anytime.

 

Canceling Appointments - Patient Responsibility 

I have read and understand my responsibility to keep my scheduled appointments and if I cannot make my scheduled appointment, I need to contact the clinic at least 24 hours in advance. 

Notice of Health Information Practices 

I understand that my healthcare provider participates in Contexture’s health information exchange (HIE). I understand that my health information may be securely shared through the HIE unless I complete and return an Opt-Out Form to my healthcare provider. 

Patient Practices/Rights & Responsibilities 

I Understand that I may obtain a printed copy of my rights and responsibilities at any time. I understand that my medical and dental information, if both services are used, will be available to both medical and dental providers at UCHC and may be used for treatment purposes. 

Telehealth (optional) I understand that I have the option to receive healthcare services using telehealth technologies, including video or audio communication. I understand the purpose, benefits, and potential limitations of telehealth, and I consent to receiving care in this manner shall I choose to schedule a telehealth appointment.