Patient Info & Forms
At UB Clinics, we want you to have the best possible experience. To expedite your visit, kindly print and complete the appropriate forms below and bring them with you to your appointment. In addition, feel free to review our Patient’s Bill of Rights below.
Complete the appropriate forms below and bring a copy with you to your appointment.
UB Clinics Intake Form
To be completed by all new UB Clinic patients except for Fones Dental Hygiene Clinic patients.
COVID-19 Informed Consent to Treat Form
To be completed by all patients for face-to-face visits after July 20, 2020.
Medical Release Form
Please complete to authorize to obtain/release medical information.
Consent to Treat a Minor
Please complete to authorize healthcare services for a minor child.
UB Acupuncture Patient Consent Form
Please complete if you are visiting the UB Acupuncture Clinic.
Fones Dental Hygiene Clinic Health History Form
Please complete if you are visiting the Fones Dental Hygiene Clinic.
As a patient, you have certain rights. Some rights are guaranteed by federal law such as the right to obtain a copy of your medical records and the right to keep them private.
At UB Clinics, we seek to provide quality care that is fair, responsive and accountable to the needs of each patient and family. In order to effectively accomplish this goal, we must work as a team to ensure that each patient is treated with respect and as an equal partner in care. You can help us make your healthcare experience safe by being an active and informed partner with your healthcare team.
As our patient, we want to make sure you understand your rights and responsibilities.You have the right to:
- considerate and respectful care.
- obtain from physicians and other direct care givers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.
- know the identity of physicians, nurses, and others involved in their care, as well as those involved are students, residents, or other trainees.
- make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and to be informed of the medical consequences of this action.
- have advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the expectation that the hospital will honor the intent of the directive to the extent permitted by law. Health care institutions must advise patients of their rights under state law and hospital policy to make informed medical choices, ask if the patient has an advance directive, and include that information in patient record.
- every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient’s privacy.
- expect that all communications and records pertaining to his/her care will be treated as confidential by health care institution, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law.
- review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law.
- expect that, within its capacity and policies, a health care institution will make reasonable response to the request of a patient for appropriate and medically indicated care and services. When medically appropriate and legally permissible, or when a patient has so requested, a patient may be transferred to another facility. The patient must also have the benefit of complete information and explanation concerning the need for, risk, benefits, and alternatives to such a transfer.
- ask and be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient’s treatment and care.
- consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent.
- expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate.
- be informed of health care policies and practices that relate to patient care, treatment, and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethic committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the facility’s charges for services and available payment methods.
In response to growing concerns about keeping health information private, the United States Congress adopted the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This privacy rule creates national standards to protect individuals' personal health information.
In keeping with HIPAA and the UB Clinics Patients Rights & Responsibilities we will consistently strive to respect personal privacy and confidentiality of information and records regarding patient care. Protected Health Information will only be used and disclosed in accordance with Clinic policies and State and Federal laws to maintain privacy of individually identifiable health information.
Each patient should expect to receive a Notice of Privacy Practices at the time of your first appointment. This document describes how your personal medical information may be used and disclosed and how to access this information.
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule requires that we develop and distribute a notice that provides a clear, user friendly explanation of your rights regarding your personal health information and our privacy practices.
If you have any questions or concerns about our Notice of Privacy Practices, please contact the UB Clinics Privacy Officer at (203) 576-2355.