Consent for Treatment/Insurance Authorization

Consent for Medical Treatment

I hereby consent to medical treatment as deemed necessary by University Health Services (UHS) providers, including x-ray examinations, laboratory tests, administration of medications, and any other diagnostic or therapeutic treatments. I acknowledge that no guarantee or assurance has been made to me as to the results of medical treatments or examinations.

Acknowledgment of Financial Responsibility

1. I understand that UHS does not contract with all health insurers and it is my responsibility to know if my health insurance provides coverage for UHS services or requires a referral or pre-approval for such services.
2. I understand that I am financially responsible to UHS for any co-pays, deductibles and/or co-insurance not covered by my health insurance.
3. I understand that certain insurance plans (including but not limited to HMOs and PPOs) designate specific providers for my health care and will not pay University Health Services for services rendered. I understand the policy of my plan, I choose to receive services at UHS, and I am aware that I am financially responsible to pay for the services that I receive at UHS.

Reference Laboratory Testing

Reference labs are used for lab testing not completed at UHS. UHS Lab utilizes Quest Diagnostics.

1. I acknowledge and understand that my insurance information will be utilized for laboratory testing at these labs.
2. I authorize UHS to send my insurance information to the reference lab for billing purposes, and I will be responsible for any charges rendered by that lab.

Insurance Authorization

1. I understand that Medical Healthcare Solutions (MHS) is contracted with UHS to provide medical billing services.
2. I authorize MHS to apply for benefits on my behalf for the medical services rendered. I certify that the health insurance information I have provided to UHS is true and accurate. I understand that if my health insurance information or coverage changes, I must notify UHS.
3. If I do not want my health insurance to be billed for the care rendered by UHS, I understand that it is my obligation to notify the UHS front office staff at the end of my visit and to complete a Self-Pay Request form. If I make this election, I understand that I will be responsible for payment in full for all charges for my care from UHS.
4. I understand that MHS and/or my health insurance company may request and receive medical information about me if UHS files a claim on my behalf. I also understand that the subscriber to my health insurance will be notified by my health insurer of the nature of these claims filed on my behalf. The subscriber is the person who is the primary policyholder for my health insurance (for example, my parent or spouse).
5. I understand that I may address any questions concerning my charges, coverage, billing or payments, to MHS at 1-800-762-9800.