CONSENT FOR TREATMENT OF A MINOR
TERMS AND CONDITIONS OF SERVICES
1. SHCS
UC Davis Student Health and Counseling Services (SHCS) is one of the health care components of the University of California.
2. MEDICAL CONSENT
I consent to any medical treatments or procedures, X-ray examinations, drawing blood for tests, medications, injections, telehealth services, taking of medical photographs, videotaping, and/or laboratory procedures rendered to the minor patient under the general and special instructions of the physicians or other medical providers of SHCS assisting in care.
Based on SHCS resources and the specific needs of the minor patient, a higher level of care or referral to specialty care outside of SHCS may be recommended. I understand that declining participation in care recommended by physicians or other medical providers of SHCS may result in SHCS being unable to provide ongoing non-urgent care.
3. TELEHEALTH SERVICES
In California, telehealth is defined as a method to deliver health care services using information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient and provider are at two different sites. This form of service usually consists of live videoconferencing through a personal computer with a webcam.
When telehealth is the chosen method of health care service delivery, you agree that the minor patient will:
- Be physically located in California during the appointment
- Be in a private location where they will not be overheard or interrupted
- Ensure that the private computer or device used has updated operating and anti-virus software
- Not record any portion of the telehealth appointment
- Wear attire that they would normally wear to an in-person appointment
4. TEACHING, RESEARCH AND HEALTHCARE INSTITUTION
The University of California is a teaching, research and healthcare institution. I understand that medical residents, medical students, students of ancillary health care professions (e.g., nursing, pharmacy, physical therapy), post-graduate fellows, and other trainees may observe, examine, treat or otherwise participate in the care of the minor patient at the request and under the supervision of a health care provider as part of the University's medical education programs
5. RELEASE OF INFORMATION:
SHCS will obtain written authorization to release information about medical treatment, except in those circumstances when SHCS is permitted or required by law to release information (see SHCS' Notice of Privacy Practices for a description of the specific circumstances under which SHCS may release this information, a copy will be provided via US mail).
6. USE AND DISCLOSURE OF MEDICAL INFORMATION:
The California Information Practices Act requires SHCS to provide the following information to individuals who supply information about themselves: As a patient of SHCS, you will be asked to submit information about the minor patient, such as their address and phone number, Social Security number, insurance information, medical history and treatment, and other personal information. The principal purpose for requesting this information is to ensure accurate identification, continuity of medical care, and payment for such care. Any use of this medical information and/or specimens by SHCS or other institutions will be in accordance with state and federal law, including all laws and regulations governing confidentiality of patient records.
7. PERSONAL VALUABLES:
I understand and agree that SHCS shall not be liable for loss or damage to any personal property the minor patient may bring to SHCS, including backpacks and purses, glasses, jewelry, clothing, or items of unusual value.
8. RECORDINGS:
I agree that while at SHCS, the minor patient shall not videotape, audiotape or otherwise record any portion of their visit or interactions, unless expressly authorized by the Associate Vice Chancellor for Student Health and Wellness or SHCS Medical Director or designee.
9. FINANCIAL AGREEMENT:
I agree to pay The Regents of the University of California for professional and clinic services not otherwise paid or covered by insurance or other sources, in accordance with the established fees in effect on the date of service. Fees incurred at SHCS are billed to UC Davis Student Accounts unless other methods of payment are mutually agreed upon prior to services rendered.
10. NOTICE TO CONSUMERS:
Medical doctors are licensed and regulated by the Medical Board of California. For information or complaints regarding medical doctors, you may contact the Medical Board of California at (800) 633-2322 and/or online at www.mbc.ca.gov.
Physician Assistants are licensed and regulated by the Physician Assistant Board. For information or complaints regarding physician assistants, you may contact the Physician Assistant Board at (916) 561-8780 and/or online at www.pab.ca.gov.
Nurse Practitioners are licensed and regulated by the Board of Registered Nursing. For information or complaints regarding nurse practitioners, you may contact the Board of Registered Nursing at (916) 322-3350 and/or online at www.rn.ca.gov/.
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.