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Consent and confirm

Click the Schedule button below to consent to care; acknowledge receipt of our Joint Notice of Privacy Practices and Patient Rights and Responsibilities; agree to financial responsibility for the visit; and confirm your appointment.

By confirming and scheduling online you are consenting to the following terms as the patient or surrogate decision maker for the patient, including minors, as defined on the Care Agreement form below. If you have questions, please do not click the Schedule button and instead call 206.520.5000 to schedule.

  1. UW Medicine Care Agreement - This is a Care Agreement. By continuing to scheduling online, you are consenting to this form and thereby giving UW Medicine providers consent to treat you, keep images related to your care, and to receive care via telemedicine technology. You also acknowledge that the benefits, risks, and alternatives have been reviewed with you.
  2. UW Medicine Joint Notice of Privacy Practices (NOPP) and Acknowledgement - We have the responsibility to protect the privacy of your information. The purpose of this form is to describe how your medical information may be used or disclosed and inform you of what your rights are with respect to your information.
  3. Patient Rights and Responsibilities - This information helps ensure that patients and their families are aware of their rights and responsibilities, and have the information that will allow them to protect their dignity and independence.
  4. UW Medicine Financial Agreement & Acknowledgement - This is a Financial Agreement and by continuing to scheduling online, you are consenting to this form and are giving UW Medicine permission to bill your insurance company.

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Harborview and UW Medical Centers, UW Medicine Primary Care

  1. Child Abuse or Neglect Reporting describes who is required to report child abuse and neglect; (b) the standard of knowledge to justify a report; (c) the definition of reportable crimes; (d) where to report suspected child abuse and neglect; and (e) what should be included in a report and the appropriate timing.
  2. Consumer Notice to learn more about your rights and protections against surprise medical bills and balance billing. For the Consumer Notice in other languages refer to our website.
  3. Emergency Medical Treatment and Active Labor Act (EMTALA) regulates how hospitals must treat patients with an emergency medical condition or who are in active labor (i.e., about to give birth).
  4. Estimate of Charges offers Information on how to request an estimate for charges related your health services.
  5. Financial Assistance may be available if you are unable to pay your remaining balance - even if you have insurance.
  6. Good Faith Estimate is provided to patients who don’t have insurance or who are not using insurance for the health care items and services they are about to receive.
  7. Hospital-Based Clinics are licensed as part of the hospital and the patient may receive a separate charge or billing for the facility, which may result in a higher out-of-pocket expense. UW Medicine Primary Care and other free-standing clinics are considered non-hospital-based clinics. Inquire with your clinic to understand if they are considered a hospital-based clinic.
  8. Medicare Shared Savings Program (MSSP) - UW Physicians (UWP) is participating in UW Medicine Choice Care, an Accountable Care Organization (ACO). ACOs have agreements with Medicare to be financially accountable for the quality, cost, and experience of care you receive. For MSSP information in Spanish click here.
  9. Notice of Joint Privacy Practices describes how medical information may be used, disclosed and how you can have access to this information.
  10. Notice of Nondiscrimination and Accessibility highlights UW Medicine’s commitment towards nondiscriminatory practices, disability assistance and interpreters services.

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