Terms and Conditions of Service

TERMS AND CONDITIONS OF SERVICE

CUSM Health is committed to delivering high-quality medical care in compliance with federal and California state laws. By signing this form, I agree to the following terms and conditions of services.

  1. CUSM Health

    CUSM Health is the clinical enterprise of the California University of Science and Medicine (CUSM). 

  2. Medical Consent

    By signing this agreement, I consent to receive medical evaluation, diagnosis, treatment, test, medications, infusions, laboratory test, medical imaging, and any other necessary services provided by CUSM Health under the general instructions of the physicians or other healthcare professionals assisting in my care. I understand that these healthcare services may involve certain risks, which will be explained to me by my provider.

  3. Teaching, Research, and Healthcare Institution

    The California University of Science and Medicine, including CUSM Health, is a healthcare institution dedicated to teaching, research, and patient care. I acknowledge that residents, medical students, trainees from ancillary healthcare fields (such as nursing, radiology, and rehabilitation therapy), post-graduate fellows, and other learners may observe, assess, treat, and be involved in my care under the supervision of the attending physician as part of CUSM’s educational 
    programs. Additionally, I understand that all research projects conducted by CUSM are reviewed and approved by its institutional review board to ensure compliance with state and federal laws. As part of this process, I may be invited to participate in research studies, but which is entirely voluntary, and my choice will not impact the care I receive. 

  4. Use of Medical Information and Specimens

    I understand that my medical information, photographs, and/or video in any form may be used for CUSM Health purposes, such as quality improvement, patient safety, and education. I also understand that my medical information and tissue, fluids, cells, and other specimens that CUSM Health may collect during the course of my treatment and care may be used and shared with researchers. I understand that under California law, I do not have any legal rights to 
    any commercially useful products that may be developed from such research. I understand that any use of my medical information or specimens by CUSM Health or other research institutions will be in accordance with state and federal law, including all laws and regulations governing patient confidentiality, in the manner outlined in CUSM Health’s Notice of Privacy Practices. 

  5. Financial Responsibility

    I understand that I am financially responsible for payment of all charges associated with my medical services received by CUSM Health. As a courtesy and for your convenience, CUSM Health will bill your insurance company if you have provided us with all the required insurance information. I also understand that, even with insurance, I am responsible for my deductible, co-payment, co-insurance, and non-covered service(s) at the time service(s) are rendered. If you are uncertain about your coverage, please contact your insurance company directly. If you choose not to bill your insurance company for care provided, it is understood that you assume financial responsibility for all charges. I agreeto pay CUSM Health for the services provided to me. If I am unable to pay, I understand that I may qualify for public assistance, and/or special payment arrangements. I also understand that when this agreement is signed by my spouse, parent, or a financial guarantor, they shall be jointly and individually liable with me for payment, including all collection fees (attorneys’ fees, costs, and collection expenses). 

  6. Release of Medical Information

    In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the State of California Information Privacy Practices Act, I understand that as a patient of CUSM Health I will be asked to submit certain personal identification information such as my photo identification, address, phone number, social security number, insurance information, medical history, and treatment. The purpose for requesting this information is to ensure accurate identification, continuity of medical care, and payment of services rendered. I understand that providing the previously mentioned information is required unless otherwise notes. I understand, not providing this information may affect my medical care and/or insurance benefits coverage. CUSM Health will obtain my written authorization torelease information about my medial treatment, except in those circumstances when CUSM Health is permitted or required by law to release information.

  7. Assignment of Benefits (including Medicare benefits)

    I authorize and direct payment to CUSM Health of any insurance benefits, including unemployment compensation disability benefits, otherwise payable to me, or on my behalf, for CUSM Health services at a rate not to exceed CUSM Health’s actual charges. I understand that I am financially responsible for charges not paid pursuant to this agreement. I also agree that any credit balance resulting from payment of insurance, or other sources, may be applied to any other account owed to CUSM Health by me.

  8. SMS Terms of Service

    By opting into SMS from a web form or other medium, you are agreeing to receive SMS messages from CUSM Health. This includes SMS messages for customer care. Message frequency varies. Message and data rates may apply. See privacy policy at www.cusmhealth.org. Message HELP for help. Reply STOP to any message to opt out.