ACKNOWLEDGMENT OF PRIVACY PRACTIES
It is the policy of UAPB Student Health Services that Student Medical Records are confidential. No information is released without the written authorization of the student except in some emergency or public health situations or under court-ordered subpoena. For in additional information see Student Health Services Confidentiality Policy. 


PERMISSION TO TREAT, AND CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION 
Student Health Services (SHS) provides and coordinates health care for students while they are in the Pine Bluff, Arkansas area. If your student requires treatment at Jefferson Regional Medical Center, Urgent Care Center, or a specialist, and community provider. Student health Services will share relevant health information as needed for continuity of care. In the event of a major health problem, whenever possible, specific permission will be obtained from you. 

• I give permission to the medical staff of UAPB Student Health Services to examine and treat my student for all health, medical, or psychological problems and injuries that may occur while they are at school. In the event that time will not allow that I be reached, or that i cannot be reached, I give permission for my student to receive health care from Student Health Services, Jefferson Regional Medical Center, and or Urgent Care Facility, appropriate specialists, and ambulance services in the event of an injury, illness or other treatment necessary to assure the continued health of the student.
• I consent to have Student Health Services use and disclose my student's protected health information for treatment, payment, and for operations purposes. 
• I understand that I will be responsible for all charges for health services by off-campus providers.