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.
COVID-19 Informed Consent to Treat
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
Please complete if you are visiting the UB Acupuncture Clinic.
Fones Dental Hygiene Clinic Health
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. (See UB Clinic’s Notice of Privacy Practices)
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, confidential and respectful care.
- Obtain from clinicians and clinical students relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.
- Know the identity of those involved in your care, including those involved who are students or 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. This includes your right to ask questions about treatment and treatment alternatives, or discontinue the treatment.
- Continuity and completion of treatment with the same clinician and/or clinical student team.
- Every consideration of privacy. Case discussion, consultation, examination, and treatment will be conducted so as to protect each patient’s privacy.
- Expect that all communications and records pertaining to care will be treated as confidential by the UB Clinics, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law.
- Review the records pertaining to your care and to have the information explained or interpreted as necessary, except when restricted by law.
- Expect that, within its capacity and policies, the UB Clinics will make reasonable response to the request of a patient for appropriate care and services.
- Ask and be informed of the existence of business relationships among the UB Clinics, educational institutions, other health care providers 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.
- Be informed of health care policies and practices that relate to patient care, treatment, and responsibilities.
- Treatment in an environment that observes Standard Precautions for the prevention of infectious disease transmission.
- To be informed of the UB Clinic’s charges for services and available payment methods prior to initiation of treatment.
If you feel any of your rights have been violated while a patient at the UB Clinics, please contact the UB Clinics Administrator.
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.