Consent for Services
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/HIPPA
I hereby acknowledge that if requested, a copy of LCSC Student Health Service’s Notice of Privacy Practices will be provided to me. I further acknowledge and understand that if I have any questions about this privacy notice, or my rights with regards to my personal health information, I may contact LCSC Student Health Services for further information as set forth in this notice.
CONSENT TO TREATMENT AND SERVICES
I hereby authorize and consent to any medical treatment and laboratory services which may be deemed necessary by the provider. I authorize LCSC Student Health Services to release any and all information to my insurance company that is required to process my claim.
STUDENT HEALTH SERVICES CLINIC RESPONSIBILITY CONTRACT
I understand that LCSC Student Health Services (SHS) is an ambulatory clinic with a limited number of appointment times available to the entire student population. In order for SHS to provide medical care for myself, I agree to the following:
- Treatment of Illness: Will be provided according to SHS policy, and only after consultation with and upon approval of the medical provider or RN.
- Coordination of Care: I understand that SHS works closely with Student Counseling/Disability Services, and authorize the release of my health information when necessary for continuity of care. This can be done without my signing an additional release of information form.
- Appointment Scheduling: I need to schedule appointments as requested and one week before medications run out. Appointments must be cancelled at least 24 hours in advance or a charge of $20 may be placed on your account.
- No Show Appointments: No shows for scheduled appointments may result in a fee of $20.
- Length of Appointment: Appointments are generally 15-30 minutes in length, depending on the nature of your appointment.
- Payment of SHS Fee for Service: The patient is responsible for payment of clinic fees incurred at each visit. Co-payment, co-insurance and deductibles will be due at the time of service. SHS accepts cash, checks, and most major credit cards. After insurance is billed, the student will be responsible for the remainder of the bill. Statements are sent out monthly, and are due within 30 days. Payment arrangements can be made through SHS by calling (208) 792-2251. Any outstanding balance not paid in 30 days, and with no prior payment arrangement made through SHS, may result in a hold on the student’s student record, which will prevent registration in future classes/semesters and will prevent the release of student transcript and/or diploma. Payment of fees and/or the establishment of a renewed payment plan will release the hold. If arrangements for monthly payments are not met, or if terms of a payment arrangement cannot be reached, I understand that my account could be turned to a collection agency. I understand that should it be necessary to employ the service of a collection agency, all collection costs and legal fees will be added to the outstanding obligation and I agree to pay the entire balance before the hold on my records will be released.
- Prescription Refills: Requests for prescription medication refills need to be made one week before the prescription runs out. Do not call SHS for your refill requests; instead, please call your pharmacy to request the refill and they will contact SHS.
- Chronic Pain Management: SHS typically does not provide chronic pain management support. Based on provider’s assessment, patient may be referred to a chronic pain management specialist.