ARTHUR ASHE STUDENT HEALTH AND WELLNESS CENTER

PATIENT INFORMATION AND CONSENT TO MEDICAL TREATMENT

I consent to the medical treatments or procedures, X-ray examinations, drawing blood for tests, medications, injections, laboratory and/or diagnostic procedures, and clinic services rendered to me under the general and special instructions of the Arthur Ashe Student Health and Wellness Center (the Ashe Center) physicians 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.

The Ashe Center will obtain my written authorization to release information about my medical treatment except in those circumstances where the Ashe Center is permitted or required by law to release information (see: Notice of Privacy Practices for a description of the specific instances under which the Ashe Center may release this information). For example, the Ashe Center may release a copy of my patient record to health plans and to other health care providers, including any provider that I may have at the UCLA Counseling and Psychological Services (CAPS), as may be medically necessary. Additionally, I understand that if I am diagnosed with a reportable disease in California, including but not limited to HIV, tuberculosis, and cancer, the Ashe Center is required by law to report my diagnosis to the State Department of Health Services or the Center for Disease Control and Prevention.

For Students with UC SHIP Insurance: I authorize the Ashe Center to bill the UC SHIP insurance plan for any services and treatments provided to me. I accept responsibility for payment for all services not covered by UC SHIP, including but not limited to, any visit fees, laboratory testing, procedure, devices, injections, and pharmacy co-payments. These charges will be billed to my university BruinBill student account.

For Students who do not have UC SHIP Insurance: I accept responsibility for payment of all expenses incurred from services provided to me by the Ashe Center. Some expenses may be covered if I have chosen to purchase BruinCare. I accept responsibility for payment for services that may include, but are not limited to, visit fees, medications, laboratory testing, procedures, devices, injections, x-rays, and supplies. These charges will be billed to my university BruinBill student account. I can obtain an itemized billing statement from the Ashe Center website and submit it to my outside insurance carrier for reimbursement consideration.

 The Ashe Center maintains a secure patient portal that allows currently registered UCLA students to access the following online services:

• Make, cancel and/or reschedule appointments
• View their patient profile and change Primary Care Provider assignment
• Communicate with their Ashe Center Primary Care Provider and other clinical staff via secure messaging
• Request medication refills
• Complete consent forms
• Print/view Itemized Statements, Immunizations and Referrals received at the Ashe Center
• Print/view the results of lab and radiology testing done at the Ashe Center

Access to the secure patient portal requires a UCLA log-in ID and password. Other UC students who do not have access to the secure patient portal can be contacted via encrypted email, including the text “#secure" in the communication.

Secure messaging should be used only for non-urgent issues.

I hereby agree to e-mail communications with the Ashe Center and/or my Primary Care Provider in accordance with these guidelines. Either I or my provider may request via e-mail or letter to discontinue using secure messaging as a means of communication.

I further agree that the Ashe Center may leave confidential voice messages for me on my home and/or cell telephone numbers.

I certify that I have read the foregoing and received a copy thereof. I am the patient, the patient's parent or legal guardian or am otherwise duly authorized by the patient to sign the above and accept its terms on their behalf.