Consent for Treatment

Student Health, Counseling and Educational Support Services Consent for Treatment

Student Health Services (SHS) and Counseling & Educational Support Services (CESS) provides health services, personal and educational counseling, psychological and learning assessment, and psychiatric services.  SHS also assists students with health and immunization requirements.

Policy for Use of Services

For SHS, students enrolled in an on-campus course (Kansas City) who pay the "Health Services" fee are eligible for services.  For CESS, students who have paid the "Educational Services" fee, residents, post-doctoral fellows and accompanying partners or family members (couples/family counseling only) are eligible for services.  Students who haven't paid these fees but are in KU academic program or are a spouse or partner of an on-campus KUMC student may receive services by paying these fees by semester.  There is no fee for a health, counseling, educational, or psychiatric appointment once the semester fee is paid.  Fees may be assessed for specific procedures, tests, or no-showed appointments.  If you have questions about fees for these services, you should contact SHS or CESS.

Consent to Release of Records

Each time I utilize Student Health, Counseling or Psychiatric Services, a record is generated. This record contains medical information about you ("medical records").  I authorize SHS or CESS to furnish requested information or excerpts from my medical records according to the uses and disclosure outlined in the Notice of Privacy Practices.  This includes release of my medical records to any insurance company, health plan or sponsoring agency who may be providing financial assistance for medical care (as well as any agents or review agencies necessary for processing any claim), including Medicare and Medicaid, for the purpose of obtaining payment; and to any physician, hospital, laboratory, radiological facility or other health care provider I am referred from or to if the release of medical records is necessary to support continuity of care.  I authorize the release of my medical records for health care operations purposes of SHS and CESS.  I understand that these medical records may include all information relative to my physical condition, past and present, including the diagnosis and history of sexually transmitted diseases including HIV/AIDS , psychiatric history and alcohol or drug abuse information. I authorize and consent to the release of information about vaccination status to schools, facilities and rotation sites.  In addition, I authorize SHS to inform the appropriate people in the event of illness that would prevent participation in academic endeavors and clinical rotations.  I consent and authorize the release of information required to comply with federal and state law. I agree that SHS or CESS, its agents and employees, are not liable if individuals or companies to whom they release medical or financial information disclose the information without my written consent.  I authorize SHS and CESS to use and disclose my medical information for the purposes of marketing or promoting services and/or activities of SHS and CESS that may benefit me. 

Client Rights & Responsibilities

  1. Evaluation: You are encouraged to discuss your progress with your provider.  If you feel that you are not making progress toward your goals, you should discuss this directly with the staff member.  If necessary, you may terminate services with the staff member or ask him or her to refer you to another department provider or external agency.
  2. Active Participation: For services to be effective, it is necessary for you to take an active role.  We invite you to be authentic, discussing concerns openly, completing outside assignments when appropriate, listening, and providing feedback.
  3. Keeping Appointments: We expect that you will notify us at least 24 hours in advance if you cannot or choose not to keep an appointment.  If there are repeated no-shows or cancellations with less than 24 hours, your slot may be given to another individual.  You may be assessed a fee for no-shows or late cancellations.  We will always attempt to contact you if we need to change an appointment.  Occasionally, an emergency will prevent us from doing so in a timely manner. 
  4. End or Begin Services with Another Agency for Counseling:  If you decide to end services or begin receiving services from another agency, we request that you discuss your decision with your provider.

Professional Staff Member Rights

  1. Refuse Services While Under the Influence of Alcohol or Drugs.  At the staff's discretion, you may be refused services if you are currently under the influence of drugs or alcohol.
  2. Terminate or Refer to Another Service Provider:  When we believe that our services are not or will not be appropriate for you, we may, after discussing our reasons with you, decide to end services and refer you to another provider or agency in the community.

Electronic Signature

By signing this document electronically, the parties agree that electronic signatures are the legally binding equivalent to handwritten signatures, and that the electronic signatures below constitute acceptance and agreement to the terms of this Agreement with the same validity and meaning as handwritten signatures.  The parties agree that they will not, at a later date, repudiate the meaning of the electronic signature or claim that electronic signatures are not legally binding. The parties further agree that the electronic version of this document bearing the electronic signatures of the parties will be considered "in writing" and "wet-signed."  The parties further agree that a printed copy of this electronically signed document will be deemed an original.

 

 

Last modified: Sep 03, 2015
ID=x24757