Protecting the privacy of your health information is important, as is ensuring you are informed about the care you receive. This page outlines our privacy practices, and explains other documents we will ask you to complete when seeking care at UChicago Student Wellness.
Like most health care providers, when you first visit UChicago Student Wellness, and periodically thereafter, we ask you to read and sign a number of documents relating to your treatment and the handling of your health information. The information below explains each of the documents we will ask you to read and acknowledge prior to your visit.
In advance of your first visit, via the myWellnessPortal, we will present you with the following four documents: (1) a Consent to Treatment; (2) UChicago Student Wellness’ Notice of Privacy Practices; (3) an authorization for UChicago Student Wellness to share information with the University of Chicago Medicine; and (4) an authorization for the University of Chicago Medicine to share information with UChicago Student Wellness. While the information below summarizes each of these documents at a high level, we invite you to read each one and make sure you are comfortable with it before signing it. Once you have signed a document, we will assume that you have agreed to its terms unless you notify us otherwise.
When you sign the Consent to Treatment, you are authorizing UChicago Student Wellness to provide you with medical care and mental health services. By signing this document, you are agreeing that UChicago Student Wellness can examine, diagnose, and treat your physical and mental health conditions and provide you with health-related advice. If you do not sign the Consent to Treatment, UChicago Student Wellness will not treat you. If you sign and later decide that you are no longer comfortable authorizing us to treat you, you can notify us, but we will no longer be able to provide you with health-related services. If you seek counseling or psychiatric care, we may also present you with additional information that provides further information specific to those services.
The Notice of Privacy Practices describes how we use and disclose the health information about you that UChicago Student Wellness collects. We understand how important it is to most people that their health and medical information is maintained in confidence. In general, we will seek your consent before disclosing your medical information to others. In some cases, we may disclose your medical information without your consent – for example, in the event of an emergency or to another provider that is treating you for the purpose of coordinating your health care. Please read the Notice of Privacy Practices carefully.
The two Authorizations to Share Health Information between UChicago Student Wellness and the University of Chicago Medicine (UCM) authorize each of UChicago Student Wellness and UCM to share information with the other about your health treatment. Many times, our students and other visitors seek additional care at UCM. Often, this is because we refer them for treatment or follow up appointments at UCM. The authorizations allow us to share information between UCM and UChicago Student Wellness without seeking further authorization from you. If you do not sign one or both of the authorizations, you can still receive treatment at UChicago Student Wellness, but it may be more difficult for us to coordinate with physicians at UCM regarding your treatment.
Students will be asked to acknowledge the forms described above via the myWellnessPortal (under the “Medical Clearances” section). We are making these PDF versions available for reference only; we ask that you acknowledge them directly in the portal, where the full text is also available.
- Consent to Treatment (PDF)
- Consent to Treatment for Minors (PDF)
- Notice of Privacy Practices (PDF)
- Authorization to Share Health Information from UChicago Student Wellness to UChicago Medicine (PDF)
- Authorization to Share Health Information from UChicago Medicine to UChicago Student Wellness (PDF)
If you have any questions about this message or any of the documents, please feel free to ask for help or clarification during your visit to the Student Wellness Center or by calling 773-834-9355.
For questions about UCM’s privacy practices, you may contact the Privacy Program at:
The University of Chicago Medicine
5841 South Maryland Avenue, MC1000
Chicago, IL 60637
Telephone Number: (773) 834-9716
Anonymous Report Line: 1-877-440-5480, Option 2
Students may request and receive their records through my.WellnessPortal. Please log in to the portal, navigate to "Downloadable Forms," and submit a completed medical or mental health request of information (ROI) form.
Former students who can no longer access my.WellnessPortal should email firstname.lastname@example.org and include a picture of a government issued ID.
Please note that Student Wellness will not accept ROI forms from third parties.
Information about the Healthcare Power of Attorney (HCPA) Form
The HCPA form is a document that allows individuals to designate someone to make healthcare decisions for them if they are unable to make decisions for themselves. Filling out an HCPA form is optional and a personal decision for the student. A student may want to discuss the HCPA with a family members or other trusted individuals. If a student chooses to complete an HCPA form, they will identify designated agents (for example, a family member and/or another trusted individual [agent]). The student and the agent should retain a copy of the signed form and may choose to forward a copy to a primary care physician or healthcare team at home.
Since the form does not come into effect until or unless the student becomes incapacitated, it may be valid for use in a hospital or emergency room setting. UChicago Student Wellness does not accept or store signed HCPA forms.
Being a Designated Agent through Health Care Power of Attorney does not automatically allow access to Student Wellness health and mental health records. Students may request a Release of Information through my.WellnessPortal. Students can log in to the portal, navigate to "Downloadable Forms," and submit a completed medical or mental health request of information (ROI) form.