Student Health Services
University of South Carolina
TREATMENT AGREEMENT & ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
TREATMENT AGREEMENT & ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
CONSENT FOR TREATMENT/ CARE:
I hereby authorize any medical or mental health treatment for myself that may be advised or recommended by the health care providers of USC. I am aware that the practices of medicine and psychology are not an exact science and I understand that no guarantees have been made to me about the results of treatments, examinations, procedures, or analysis.
ACKNOWLEDGMENT:
I attest that this office has given me a copy of its Notice of Privacy Practices to review. The Notice describes how medical information about me may be used and disclosed and how I can gain access to this information. I understand that it is the responsibility of this office to provide me with a copy of its Notice on the first services encounter after August 25, 2013. If my first date of service with this office was due to an emergency, I understand that it is the office’s responsibility to provide me with this Notice and obtain my signature as acknowledgment of receipt as soon as possible following the emergency.
I hereby authorize any medical or mental health treatment for myself that may be advised or recommended by the health care providers of USC. I am aware that the practices of medicine and psychology are not an exact science and I understand that no guarantees have been made to me about the results of treatments, examinations, procedures, or analysis.
ACKNOWLEDGMENT:
I attest that this office has given me a copy of its Notice of Privacy Practices to review. The Notice describes how medical information about me may be used and disclosed and how I can gain access to this information. I understand that it is the responsibility of this office to provide me with a copy of its Notice on the first services encounter after August 25, 2013. If my first date of service with this office was due to an emergency, I understand that it is the office’s responsibility to provide me with this Notice and obtain my signature as acknowledgment of receipt as soon as possible following the emergency.