Intercollegiate Athletics Policy Manual

4.00 Camp Policy Manual

APPENDIX - Medical 15.30.16 Camp Use of UHS

THE UNIVERISTY OF TEXAS AT AUSTIN SUMMER SPORTS PROGRAM
REQUEST TO USE UNIVERSITY HEALTH SERVICES

Eligibility:  Medical services at the University Health Services (UHS) are limited to registered students who pay a Medical Services Fee each academic term.  Exceptions may be granted to outside groups with institutional sponsorship for limited periods of time through prior agreement.

Agreement: UHS agrees to provide medical services for acute illness or injury to participants in the University-sponsored summer program identified below for $40.00 per visit plus any charges incurred for ancillary services -e.g. lab, tests, x-ray, medications, or treatment procedures.  If the department is not paying for all charges incurred at UHS, program participants are responsible for payment of services rendered at UHS.  Filing of insurance claims is the responsibility of the insured.  Any unpaid charges will be the responsibility of The University department sponsoring the program and will be charged to the account number noted below if the program participant refuses to pay in a timely manner.

Program/Conference Name: 

Dates of Program:

Type of Group Participants:
  q  Minor with Chaperones (Must bring "Consent For Treatment/Immunization of a Minor Who Does Not
  Have Legal Power to Consent" form signed by parent or guardian)

  q  Adult

Total Participants in Program:
  Ä  Please forward a list of participants with dates of births and home addresses as soon as
  possible.

Complete Only if Program Participants are Minors:
  Our program will provide the "Notice of Privacy Practices" to parents/legal guardians:
  q  In hard copy
  q  Via referral to a program-related website

Coordinator of Program/Conference:

 

Name: 
Title:
Mailing Address: 
E-mail Address:
Phone No.:
UT Account Number: 
Please Check One:
  q  Our program will pay for all charges incurred at UHS by our program participants.
  q  Our participants are responsible for paying any charges they incur at UHS; however, I understand that our program will be billed for all participant's charges that are unpaid as of 10/31/04.

       
Signature of Requesting Sponsor Department   Date

UHS can only offer services to participants of those groups that have returned this completed form.  Please mail this form and a list of program participants to:

  (On-Campus Coordinators) Sherry Bell, University Health Services, SSB 2.212, A3900
  (Off-Campus Coordinators) Sherry Bell, UT-Austin University Health Services, P.O. Box 7339, Austin, TX 78713

 

 

last updated: February 11, 2009