Forms and Policies

• Patient Consent and Release for Screening COVID-19

• Authorization To Release Health Information - Once completed, this form enables UT Health Austin to share your medical record with another provider, or healthcare entity.
• Autorización para divulgar información de la salud - Una vez completado, este formulario permite a UT Health Austin compartir su expediente médico con otro proveedor o entidad de atención médica.
• Authorization to Receive Medical Records - Once completed, this form allows UT Health Austin to request your medical records from another provider or healthcare entity.
• Autorización para recibir registros médicos - Una vez completado, este formulario permite a UT Health Austin solicitar sus registros médicos de otro proveedor o entidad de atención médica.
• Authorization to Share Health Information - Once completed, the form allows your provider to discuss (verbally) your health information with another provider or healthcare entity.
• Autorización para Compartir Información de Salud - Una vez completado, el formulario permite a su proveedor discutir (verbalmente) su información de salud con otro proveedor o entidad de atención médica.

Notice Concerning Complaints

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

Aviso Sobre Las Quejas

Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

• UTHA Referral Form - Print and complete this form and fax to: 512-495-5680
• Comprehensive Memory Center - Due to a current waitlist of 4-6 months, at this time only internal referrals from UT Health Austin providers are being accepted.
• Livestrong Cancer Institutes and Surgical Oncology - Print and complete the UTHA Referral Form and fax to: 512-495-5709
• Authorization To Release Health Information- to expedite the referral process

Discrimination Is Against the Law

UT Health Austin complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. UT Health Austin does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

UT Health Austin provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)

UT Health Austin provides free language services to people whose primary language is not English, such as:

• Qualified interpreters
• Information written in other languages

If you need these services, please contact the Front Desk Personnel at any of our clinics.

If you believe that UT Health Austin has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Office
100 West Dean Keeton, Suite 3.212
Austin, Texas 78712, 512.471.1849
equity@utexas.edu

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Office of Inclusion and Equity is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html.

Download a copy of this policy in here (English and Spanish).

Approved: 11/3/2023

Approving Body: CEPAS

1. I. Policy

To set out rules for video and audio recording, and photographs by patients, families, visitors, or non-UT Health Austin (UTHA) staff using their own electronic devices during virtual, telehealth, or in-person visits, in both clinical and non-clinical areas (e.g. a waiting room) within the UTHA facilities.

This policy should be read with the UTHA Standards of Conduct for Patients, Families, and Visitors.

This policy can also be found within the new patient paperwork, and should be acknowledged and signed by each patient.

1. II. Scope

This policy applies to patients, families, visitors, and non-UTHA staff during both in-person and telehealth visits.

III. Procedures

• Patients and non-UTHA individuals may not use their own electronic devices (a) to take photographs or (b) to record video or audio conversations, about the patient’s own treatment, procedure, service, or medical records without first verbally requesting and obtaining verbal consent from the treating provider(s) or UTHA staff member(s) who will be included in the photographs or the recording. At any point, if they deem it necessary, the provider(s) or the UTHA staff member(s) may withdraw consent and request that the recording be deleted.
• Patients and non-UTHA individuals may not use their own electronic devices to take personal, non-clinical photographs, or to make video or audio recording in this setting.

Patients and non-UTHA individuals must respect the decision made by the treating provider(s) and the UTHA staff member(s) for consenting to or refusing to consent to being photographed or audio/visually recorded.

Download a copy of this policy here.

REFERENCE

UTHA Standards of Conduct for Patients, Families, and Visitors

Download a copy of this policy in English and Spanish.

At UT Health Austin, we strive to create a welcoming and respectful environment for our medical teams to deliver healthcare for you and your family. We encourage you to participate in your care process. Together, by working with you in a safe, respectful, and honest way we can provide the best care to you.

To ensure the best care experience for yourself, other patients, and your care teams, we respectfully request that you:

• Be considerate when using your cell phone or other electronic devices at UT Health Austin.
• Arrive on time for your appointment, ideally 10-15 minutes early. To respect the time and needs of patients who do arrive on time, any patient who is more than 30 minutes late for a scheduled appointment may not be seen and will likely be rescheduled.
• If you must cancel an appointment, we ask that you please do so as soon as possible, at least 24 hours in advance. We know that plans may change at the last minute, so even late notice is appreciated. Patients who miss more than 3 appointments may not be able to be rescheduled and will be notified.
• You must get permission before taking photographs/videos or voice recordings of anyone on your medical team.

To ensure a safe and respectful working environment, UT Health Austin finds certain behaviors to be unacceptable. These behaviors could lead to removal from the building and/or dismissal from the clinic.

Examples of unacceptable behaviors are:

• Disrupting another patient’s care or experience
• Bullying, intimidating, harassing staff or other patients
• Engaging in: profanity, assault, or infliction of bodily harm to self or others
• Engaging in or threatening violent behaviors either in person or in communications
• Making vulgar or derogatory remarks associated with race, ethnicity, sexual orientation, culture, language, age, disability, veteran status, or immigration status
• Requests, demands, or denial for clinical, learners, or another staff member (s) based on the above
• Damaging UTHA property or equipment
• Possessing illegal weapon(s) in prohibited areas
• Making requests that would constitute unethical or illegal behavior on the part of UTHA

UTHA has a zero-tolerance policy for aggressive behavior directed toward our providers, learners, and staff. If you personally experience or notice any alarming or unsafe behaviors, please report them to a member of our staff immediately.

Download a copy of this policy in English or Spanish.

Approved: 1/12/24

UT Health Austin (UTHA) and Dell Medical School (DMS) will reasonably accommodate patients and visitors with their service animals in compliance with federal[1] and state[2] laws, and this policy. A service animal means an animal (generally a dog) that has been specially trained or equipped to perform specific tasks directly related to the handler’s disability. Animals whose sole function is for emotional support, therapy, comfort, or companion are not considered service animals.

A service animal:

• Will be permitted to accompany its handler and enter the UTHA/DMS premises open to the public;
• May be permitted to accompany its handler and enter the areas not open to the public. Gaining admittance to such areas will be determined on a case by case review by the Executive Director of UTHA.
• Will not be permitted to accompany its handler and enter sterile areas, or clean rooms, where special precautions (such as wearing gloves, masks, and/or gowns) are required for the purposes of infection control. These areas include but are not limited to operating rooms, procedure rooms, recovery rooms, and other sterile areas.

A service animal may be denied admittance to or removed from the UTHA/DMS premises if the service animal:

• Exhibits aggressive behavior including, but not limited to, biting, excessive whining, barking, growling, scratching, or teeth baring;
• Is excessively noisy;
• Poses a direct risk to the safety and health of other service animals or people;
• Is not under the control of the handler;
• Is not well groomed or does not appear healthy, in which case our staff will ask for proof of vaccination or the dog’s health records prior to entering the premise.

It is the patient/handler’s responsibility to supervise, control, and care for the service animal, including the removal of the animal from the premises. UTHA/DMS will coordinate an alternative care for the animal at the handler’s expense if handler cannot perform such responsibilities.

Under the applicable laws, our staff will not ask you of the following:

• The qualifications of the service animal or the nature of the person’s disability;
• Require or request medical documentation, special identification card or training documentation for the service animal;
• Request that the service animal demonstrate its ability to perform the work or task.

However, in situations where the handler’s disability is not readily apparent, our staff may ask the following questions for clarification:

• Is the dog a service animal required because of a disability?
• What work or tasks has the dog been trained to perform?

The service animal that enters the premises must always be on a leash or harness.

If you have questions about bringing service animals onto the UTHA/DMS premises, contact the Executive Director of UT Health Austin and/or the Compliance Office.

Download a copy of this policy here.

[1] https://www.ada.gov/2010_regs.htm

[2] https://gov.texas.gov/organization/disabilities/assistance_animals#responsibilities