Consent and Agreement for Treatment Consent to Collect, Create, Use, Maintain and Disclose Your Health InformationConsent and Agreement for Treatment • November 24th, 2014
When we examine, diagnose, treat, or refer you we will be collecting what the law calls Protected Health Information (PHI) about you. This information may include your health records, health history, symptoms, examination and test results, diagnosis, treatment, treatment plans, and billing and health insurance information. We need to use this information to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment, or for other business (such as supervision) or required government functions (such as reporting abuse).
Consent and Agreement for TreatmentConsent and Agreement for Treatment • October 7th, 2020
When we examine, diagnose, treat, or refer you we will be collecting what the law calls Protected Health Information (PHI) about you. This information may include your health records, health history, symptoms, examination and test results, diagnosis, treatment, treatment plans, and billing and health insurance information. We need to use this information to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment, or for other business (such as supervision) or required government functions (such as reporting abuse).
The University of Texas Health Science Center at San Antonio Dental School CONSENT AND AGREEMENT FOR TREATMENTConsent and Agreement for Treatment • February 23rd, 2009
Please read the following information carefully. After you have read this Consent andAgreement, please sign your name below to accept the terms of this agreement. 1. Consent to treat: As a consenting adult, I agree to permit the students, faculty, staff and residents of The University of Texas Health Science Center at San Antonio Dental School (UTHSCSA‐DS) to provide dental care to myself, my child or patient representative as applicable. 2. Teaching facility: As a patient of UTHSCSA‐DS, all treatment will be provided by faculty or by students or residents of the Dental School under the supervision of clinical faculty. 3. Limitations: Not all persons can be accepted as patients of UTHSCSA‐DS. Persons with complicated medical conditions, rigid time requirements, and extremely difficult dental care needs may not be accepted. I understand that if I am accepted as a patient, my treatment at the UTHSCSA‐DS may be limited, after which time I would need to find dental care outside the Dental
CONSENT AND AGREEMENT FOR TREATMENTConsent and Agreement for Treatment • March 17th, 2007
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
CONSENT AND AGREEMENT FOR TREATMENTConsent and Agreement for Treatment • November 26th, 2012
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
CONSENT AND AGREEMENT FOR TREATMENTConsent and Agreement for Treatment • November 28th, 2017
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
Consent and Agreement for TreatmentConsent and Agreement for Treatment • January 30th, 2022
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
Urgent Behavioral Health CareConsent and Agreement for Treatment • April 29th, 2021
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement. Please initial next to each item.
