II.K REFERRALS TO UCSC EMPLOYEES WITH PRIVATE PRACTICES

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Wed, 05/27/2015
Revised: 
Fri, 06/13/2014
Policy: 

Referrals to private practices in which CAPS clinicians may have personal or financial interest represent a potential conflict of interest. It is important to avoid both actual conflict of interest and the appearance of impropriety in making referrals. The CAPS Center may refer a UCSC student to a UCSC-employed clinician’s private practice, or to a practice in which a UCSC-employed clinician has a financial interest, when all of the following conditions are met: 

  1. The care for which the student is being referred is not normally available at CAPS.
  2. The clinician has provided the student with the names of at least two other appropriate practitioners, not associated with the University, in private practice in the community.
  3. Self referals are not permitted.  
  4.  Referals to near relatives are not permitted.

NOTE: For more information on the University of California Conflict of Interest Code, see http://finaff.ucsc.edu/cc/ARH/HScoi.htm or http://www.ucop.edu/general-counsel/_files/uc_coi_code.pdf

AGREEMENT TO OFF CAMPUS REFERRAL

TO UCSC-EMPLOYED CLINICIAN’S PRIVATE PRACTICE

I, _________________________________________, wish to seek psychiatric/psychotherapeutic care off campus.(name of student)

I wish to see _________________________________________ in his/her private practice.
(name of clinician)
I am aware that the UCSC CAPS will not pay for this service, and is not responsible for care provided in the private practice setting.

____________________________________________ has explained to me that this referral
(name of clinician)

is for services not normally available at CAPS, and has given me the names of at least two other local practitioners not associated with the University.

Student signature ________________________________________ Date ______________
Student name___________________________________________
Student I.D.# ___________________________________________

You are being referred to a non-UC health care provider for additional care. Your licensed provider may have a financial interest or family relationships with a clinician that he/she is referring you to. You understand that you may request and get more information related to the interest prior to seeing the non-UC provider.  You acknowledge that you have been referred to at least two additional providers in whom your clinician has no financial interest or personal relationship.