top of page

Consent for Treatment 

I consent to examination, diagnosis, and general medical care and treatment (including, but not limited to, physical examinations, administration of medications and vaccinations, recordings and/or photographs for diagnosis and/or treatment, the taking of x-rays, blood draws, diagnostic tests, laboratory tests, and other minor procedures) to be performed by employees, including but not limited to physicians, mid-level provider (Physician Assistant or Nurse Practitioner), certified medical assistants, and radiology technician of UCHA/MDCUC. 

You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you. If you have any concerns regarding any test or treatment your healthcare provider recommends, we encourage you to ask questions.

I understand that my protected health information will be used by UCHA/MDCUC,  as necessary, for my treatment, to obtain payment for treatment, and for the healthcare care operations of UCHA/MDCUC.  I also understand that my protected health information will be disclosed to other UCHA/MDCUC.  affiliated if needed to further my treatment, obtain payment for treatment, and the healthcare operations for UCHA/MDCUC. I understand that UCHA/MDCUC. will warn the appropriate authorities and/or other individuals if my UCHA/MDCUC medical provider determines that I am a harm to myself or others. 

Assignment of Benefits

I authorize my insurance carrier to assign all surgical and/or medical benefits to MDCUC if applicable. I also authorize the release of medical information necessary to process all medical insurance claims.

Referral Policy

I understand that it is my responsibility to obtain referrals through my primary care physician’s office if required by any consulting physicians and or diagnostic centers.

Payment Policy 

Co-payments are to be collected at the time services are rendered. We accept Cash, Visa, Mastercard, and Discover. All medical services provided are directly charged to the patient or responsible party. If your physician is contracted with your insurance carrier, as a courtesy, we will submit all claims and necessary information to your insurance for payment. However, you will be responsible for any balance deemed a deductible, co-insurance, patient responsibility, non-payable, or non-covered by your insurance and billed accordingly. Payment is expected in full upon receipt of the statement, or payment arrangements must be made with our billing department.

Narcotic or Controlled Substance Policy

The medical providers at UCHA/MDCUC do not routinely prescribe narcotics on a long-term basis, nor do we administer narcotics by injection in the clinic. No narcotic medications are kept on site. Individuals who are seeking “painkillers” for chronic use are hereby advised to seek treatment with appropriate pain management clinics or, if the pain is severe, with the local hospital emergency department. When indicated, long-acting opiates are prescribed in extremely limited quantities without automatic refills and will not be refiled. Furthermore, patients desiring prescriptions for controlled substances from our office grant us permission to contact pharmacies, other physicians, and controlled substances databases to ensure compliance with this policy. If determined that multiple physicians are ordering prescriptions for pain or any other controlled substance, we will immediately cease all orders for such treatment from our offices. 


I have read and fully understand UCHA/MDCUC Notice of Information Practices and Policies. I understand that UCHA/MDCUC may use or disclose my personal health information to carry out treatment and obtain payment, evaluate the quality of services provided, and perform any administrative operation related to treatment or payment. I also understand that it is UCHA/MDCUC’s policy to send reports to my primary care physician, referring physician, and other physicians associated with my care. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations. I will notify UCHA/MDUC in writing. I also understand that UCHA/MDCUC will consider requests for restriction on a case-by-case basis but does not have to agree to request restrictions. 


I hereby consent to using and disclosing my personal health information for the purpose noted in UCHA/MDCUC’s Notice of Information Practices. I understand I retain the right to revoke this consent by notifying UCHA/MDCUC in writing. 

bottom of page