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Patient Forms and Policies

Consent to Treat and Health Care Agreement

Effective:  August 17, 2025

You can view an online version from your mobile device or request a copy at the Student Health Center Front Desk.

Consent to Treatment

The 色花堂 Student Health Center is an integrated healthcare facility that provides medical and mental health services.

As a patient, you have a right to be informed about your diagnosis, suggested courses of treatment, and any risks or hazards of the suggested treatment so that you may make informed decisions regarding your course of care.  At this point, no specific treatment plan has been recommended.

By signing this form, you permit the 色花堂 Student Health Center to perform reasonable and necessary medical examinations, testing, and treatment.  This includes administering recommended immunizations upon request or carrying out indicated tests (i.e., labs, urine drug screening, etc.) or treatment.  Further, you authorize the 色花堂 Student Health Center to refer you to another licensed physician for necessary continuation of care.

Please be advised, in the event a 色花堂 Student Health Center staff member is exposed to your blood or other bodily fluid, you may be asked to undergo testing for certain communicable diseases (such as HIV, hepatitis B, and hepatitis C).  This testing will help ensure the safety and health of you, other patients, and the 色花堂 Student Health Center staff.  Your participation in such testing will require your informed consent at that time, and the results will be handled in accordance with all applicable privacy laws and regulations.

You have the right to discuss the purpose of the proposed treatment, potential risks, alternatives, and benefits of any test or treatment ordered for you with your provider.  If you have any concerns regarding any test or treatment recommended by your health care provider, then you are encouraged to ask your health care provider or other 色花堂 Student Health Center staff questions.  Furthermore, you have the duty to inform your 色花堂 Student Health Center provider of any past or present health care treatment that you have received, or are receiving, by another health care provider that may be relevant to the treatment provided by the 色花堂 Student Health Center.  

 
Confidentiality

The 色花堂 Student Health Center recognizes that confidentiality is essential to effective medical treatment.  Therefore, your medical information will not be released without your written authorization except as otherwise permitted by law or as indicated by this consent form. Circumstances that may lead to disclosure without consent include:

  1. Information released to other health care professionals or the 色花堂 Student Health Center staff involved in your treatment.  Most commonly, this information will be used for the purpose of treatment, payment, or operations;
  2. A 色花堂 contractor, business associate, volunteer, or any other party that is performing services on behalf of the 色花堂 Student Health Center;
  3. If you are under 18, your parents or legal guardian(s) may have access to your records and may authorize release of your records to other parties;
  4. If you are reasonably suspected to be in imminent danger of harming yourself or someone else;
  5. To report abuse or neglect of children, the elderly, or disabled persons;
  6. To comply with a mandate to transmit statistics to the University regarding sexual misconduct by or against you that you report to the 色花堂 Student Health Center during your treatment and that occurred while you were employed or studying at 色花堂.  We will only indicate the type of incident that is reported, and we will not include information that would violate your expectation of privacy.  The reporting of these statistics will not trigger an investigation by the University;
  7. To qualified personnel for certain kinds of program audits or evaluations;
  8. In criminal proceedings;
  9. In legal or regulatory actions against a professional;
  10. Upon the issuance of a court order or lawfully issued subpoena;
  11. If assistance from legal counsel is deemed necessary to handle a records request; or
  12. Where otherwise legally permitted.

 

The above is considered only to be a summary of the circumstances that may lead to the disclosure of your records.  Your health records will be destroyed either ten years after your last contact with the 色花堂 Student Health Center or once you reach the age of majority, whichever is later.  Health records will be destroyed in a way that protects your privacy.  If you have any questions about specific situations or any aspect of the confidentiality of the 色花堂 Student Health Center鈥檚 records, please ask a member of the 色花堂 Student Health Center.

Telemedicine Consent

The 色花堂 Student Health Center will provide services through limited telemedicine during mandatory health-related university closures or when determined to be appropriate by a Student Health Center provider.  By signing this form, you consent to participate in telemedicine with the 色花堂 Student Health Center.  Telemedicine is the practice of delivering health care services via technology-assisted media or other electronic means between a health care provider and a patient located in two different locations. 

By signing this form, you are acknowledging that you understand the following with respect to telemedicine: 

  1. The same standard of care applies to a telemedicine visit as applies to an in-person visit.
  2. You will not be physically in the same room as your health care provider.  If anyone is present in the room with your health care provider, you will be notified and your consent will be obtained.
  3. You must be physically located in the state of Texas while receiving telemedicine services from the 色花堂 Student Health Center.  Your provider will verify your physical location at the beginning of each telemedicine session.  You must notify your provider immediately if you are located outside of Texas.
  4. You have the right to withdraw consent or decide to stop participating in a telemedicine visit at any time.  Your refusal will not affect your right to future care or services at the 色花堂 Student Health Center.
  5. There are risks unique to telemedicine, including but not limited to, disruption of transmission by technology failures, interruption, and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
  6. There will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without your written authorization, except where the disclosure is permitted and/or required by law.
  7. The privacy laws that protect the confidentiality and privacy of health information also apply while receiving telemedicine services unless an exception to confidentiality applies (as outlined above).
  8. During a telemedicine session, either party may encounter technical difficulties resulting in service interruptions or interceptions.  If this occurs, you shall end and restart the session immediately.  If you are unable to reconnect within ten minutes, please call the 色花堂 Student Health Center at 713-743-5151 to reschedule the visit.
  9. You have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information.
  10. Your provider may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

Financial Responsibility

By signing this Informed Consent agreement, you hereby acknowledge that you have received the 色花堂 Student Health Center Financial Responsibility Agreement.  Further, you hereby acknowledge and agree to the terms of the 色花堂 Student Health Center Financial Responsibility Agreement, and you understand that you are financially responsible for any in-person or telemedicine services rendered by the 色花堂 Student Health Center.  If labs or testing are ordered, these services may be provided by a health care facility outside of the 色花堂 Student Health Center, and you will be responsible for the cost of these services.

Should you have any questions regarding the cost of your treatment, you are encouraged to contact or visit the 色花堂 Student Health Center. 

 Acknowledgment

By signing this form, you acknowledge and agree to the following:

  1. This document will become a part of your medical record.
  2. You have read, understood, and agree to abide by the information, terms, and conditions contained in this consent.
  3. You have had the opportunity to discuss any questions about the information contained in this form or any other aspects of the services provided at the 色花堂 Student Health Center.
  4. You hereby give your voluntary and express consent to the 色花堂 Student Health Center to evaluate, provide medical treatment for minor or non-emergent illnesses or injuries, and/or refer you to other external providers as needed.
  5. Your treatment is voluntary, and you may terminate your treatment with the 色花堂 Student Health Center at any time.
  6. You hereby give your voluntary and express consent and agree to the uses and disclosures of your health information as described above.

This consent will remain fully effective until consent is revoked in writing. You have the right to discontinue services at any time.

Acknowledgment of this agreement is obtained electronically or on a separate form.