Email Communication
If at any time, I provide an email address at which I may be contacted, I consent to receive lab-related information, promotions, and other communications from the United Community Foundation (UCF).
General Consent
I grant permission to United Community Foundation (UCF) to perform certain screening tests as ordered by my doctor. I understand I may request specific tests under my own direction, in which case I will be responsible for all payment-related obligations.
The tests may involve obtaining specimens of blood by venipuncture or fingerstick, urine samples, or other sample collections. I authorize UCF to mail or email my test results to me.
If any critical test values are obtained, I authorize UCF to contact me promptly by telephone or email. If they cannot reach me, I give permission to contact my emergency contact.
I understand that UCF will not submit self-directed tests to insurance companies and that test results will not be forwarded to medical professionals unless ordered by a medical provider.
Financial Policy
All lab services provided by UCF are billable to the patient. The fees are payable at the time of service, and I am solely responsible for the payment. I am also liable for any co-payments, coinsurance, deductibles, or other amounts not covered by insurance.
I understand that UCF will not submit claims to insurance companies for self-directed tests. If insurance is used, I authorize UCF to bill my insurance company for services rendered and understand that I am responsible for any unpaid or out-of-pocket expenses.
Release of Information
I authorize UCF to use or disclose my protected health information to any authorized agent for healthcare, treatment, and payment purposes, as described in the Notice of Privacy Practices.
I understand that my consent is not needed if the law requires UCF to report any aspect of my protected health information to a government agency.
Notice of Privacy: HIPAA 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 have the right to review the UCF Notice of Privacy Practices/Patients' Rights, which is available upon request.
Complaints
If I wish to file a grievance or complaint with the Texas Medical Board or UCF's Compliance Manager, I can contact them via email at ceo@ucftexas.org or by calling 281-853-5555.
