Dba Sample

396 Words2 Pages
PATIENT CERTIFICATION, CONSENT FOR TREATMENT, AUTHORIZATION TO RELEASE INFORMATION, AND PAYMENT AGREEMENT CERTIFICATION I certify that the information given by me is correct, I authorize [health center name]. DBA [health center name] to release medical or other information about me to Social Security Administration, Medicare Program or its intermediaries or carriers, Medicaid, as well as private insurance claims to the necessary insurance carriers and/or the Professions Standards Review Organization. I request that payment of authorized benefits be made on my behalf. CONSENT FOR TREATMENT I hereby request services from [health center name]. DBA [health center name] and give my consent for the staff to administer and perform medical…show more content…
Payment is expected at the time of service. I acknowledge my responsibility for myself and my dependents to pay the charges determined by [health center name]. DBA [health center name]. I understand that the information pertaining to the sliding fee scale assessment will be verified by the organization. ________________________________________ _______________ ______________ Signature of Patient, Parent or Legal Guardian Interviewer Date Acknowledgement of Receipt of Notice of Privacy Prueba de recibo de “Aviso de Practicas privadas” I, _____________________________ have received the Yo _______________________he recibido una Notice of Privacy Practices from [Health Center Name] copia de “Aviso de Practicas Privadas” de la clinica [health center name]. X____________________________ Date_____________ Firma___________________________ Fecha______________ In lieu of patient signature I, _______________________ a Yo, _____________________________como empleada (o) de la Staff member of [health center name]. clinica. Testiga(o) de la frima del
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