Emergency Contact Information

General Consent: I hereby grant permission to United Community Foundation (UCF) to perform certain screening tests as per the orders by the doctor. I may request the UCF to do specific tests under my own direction – in that case, I will be liable for any and all payment related to my self-directed tests. The tests may include obtaining specimens of blood by venipuncture or finger stick or swab, or urine and other means of sample collections. I authorize the UCF to obtain these screening results and mail or e-mail them to me at the above addresses.

The testing that is not ordered by a physician or other medical provider, is being done for my own use and not for medical diagnostic or treatment purposes. However, I will contact the medical provider for any abnormality in the tests. I will not hold UCF liable for any condition, damage, or abnormality.

The UCF will not submit self-directed tests to any insurance company for reimbursement. I further understand that the test results will not be forwarded to any medical professional for diagnosis of any medical condition unless ordered by the medical provider. If testing returns critical values which may indicate a serious medical condition, the UCF will make reasonable attempts to notify me promptly, including by telephone and by leaving voicemail. If the UCF is unable to reach me, I give permission to contact the emergency contact listed above to report the critical values. It is my responsibility to share the test results with my physician at my sole option. I am responsible for obtaining medical information, treatment or services from a doctor or other health care provider in relation to the test results.

Financial Policy: All labs and related services provided by UCF are billable to the patient. The fees of the services are payable at the time of the service and is sole responsibility of me “the patient” and/or guarantor of minor (my children).

Insurance: I am liable to provide all insurance information and medical provider’s orders for the lab testing services. I hereby authorize SHC to bill my insurance concerning services rendered to me or my dependents covered in the insurance. I understand that I am responsible for any co-payment, coinsurance, deductible, or any other amount not covered or unpaid by the insurance to UCF. I have read and understand the financial policy of UCF and accept the terms.

Release of Information: I hereby authorize the UCF to use or disclose my protected health information to any authorized agent for the purposes of healthcare, treatment, and payment as described in the Notice of Privacy Practices. I authorize the release of medical information to my insurers as necessary for determination and payment of benefits; to healthcare providers involved in my care; to utilization review and professional standards review organizations, companies, and community resources that assist me with my healthcare needs.

I understand that my consent is not needed if the law requires UCF to report some aspect of my protected health information to a government agency.

Notice of Privacy: HIPPA ACKNOWLEDGMENT: I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain patient rights regarding my protected health information. I understand that I have the right to review UCF Notice of Privacy Practices/Patients’ Rights and the most recent copy is available upon request.

Complaints: I understand that if I wish to file a grievance or complaint with the Texas Medical Board or UCF’s Compliance Manager, I can contact via email at [email protected], or by calling at 281-853-5555.

The consent will remain in full force until revoked in writing. I also understand that by refusing to sign this complete consent or revoking this consent, UCF may refuse to provide me service.

I certify that I have read and fully understand the above statements and consent fully and voluntarily. I hereby acknowledge that I have had an opportunity to ask any questions about its contents, procedure, and policy.

By signing below, I consent to undergo the laboratory testing under the conditions set forth herein.

I hereby state that to the best of my knowledge, the above information is current, correct, and true. I understand that it is my responsibility to inform SHC Lab in case me or my minor child, have changes in any of the information provided above.

I, the undersigned, hereby authorize and direct my insurance carrier to pay directly to UCF, as per my insurance plan. I
further agree to pay the balance of the charges not paid by my insurance. Any balance that is not paid within 60 days will
also be my responsibility. I hereby authorize the release of any information necessary to secure payment of benefits. I also
authorize the use of this signature on all insurance submissions. Further, I as a parent / legal guardian give consent for
treatment for this, and future services rendered to the minor covered under my insurance plan.

A minor is an individual who is under 18 years of age who is not and has been married or had the disabilities of minority not been removed by the court.
I , _____________________________ , am the [Parent/Legal Guardian] of the minor child above, and have the power
to consent for health care services for him/her. I hereby voluntarily consent to authorize the UCF staff to provide lab
testing services to the above minor. I understand that this consent is valid and remains in effect as long as the minor is a
client of the UCF and I state that I have sufficient information, capacity, and authority to give this consent.

I, hereby delegate authority to consent to perform medical/dental treatment as per the statements above when
accompanied by the following named adult persons over the age of 18:

(Grandparent, Aunt, Uncle, Sister, Brother, Family Friend)