Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:
Appears in 58 contracts
Samples: Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) ), patient should initial below:here. . Effective as of the date of first professional services.
Appears in 24 contracts
Samples: Arbitration Agreement, Arbitration Agreement, Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here. . Effective as the date of first professional services.
Appears in 12 contracts
Samples: Arbitration Agreement, Arbitration Agreement, Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:.
Appears in 7 contracts
Samples: Therapist Patient Arbitration Agreement, Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:.
Appears in 3 contracts
Samples: Arbitration Agreement, Arbitration Agreement, Health Care Provider Patient Arbitration Agreement
Retroactive Effect. If patient intends this agreement Agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:;
Appears in 3 contracts
Samples: Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement
Retroactive Effect. If patient Patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:effective as of the date of first medical services.
Appears in 3 contracts
Samples: Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here. . Effective as of the date of first professional services.
Appears in 3 contracts
Samples: Arbitration Agreement, Arbitration Agreement, Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example), emergency treatment) patient should initial below:here _. Effective as the date of first professional services.
Appears in 3 contracts
Samples: Arbitration Agreement, Arbitration Agreement, Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:here: . This agreement is thus effective as of the date of first medical services..
Appears in 2 contracts
Samples: Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here . Effective as the date of first professional services.
Appears in 2 contracts
Samples: Arbitration Agreement, California Arbitration Agreement
Retroactive Effect. If patient Patient intends this agreement Agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient ), Patient should initial below:the following: Effective as of the date of first medical services: [Initial Here]
Appears in 2 contracts
Samples: Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement
Retroactive Effect. If the patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:.
Appears in 2 contracts
Samples: Physician Patient Arbitration Agreement, Physician Patient Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below: I have read and understand the above information. Patient Signature: Date:
Appears in 2 contracts
Samples: Arbitration Agreement, Arbitration Agreement
Retroactive Effect. If the patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:
Appears in 2 contracts
Samples: Physician Patient Arbitration Agreement, Physician – Patient Arbitration Agreement
Retroactive Effect. If the patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here . Effective as the date of first professional services.
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:for example,
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here. Effective as the date of first professional services.
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If a patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here _ . Effective as the date of first professional services.
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here. __________. Effective as the date of first professional services.
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If patient Patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient ), Patient should initial below: Effective As of Date of First Medical Services:
Appears in 1 contract
Samples: Provider Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date dates it is signed (including, but not limited to, emergency treatment) patient should initial below:
Appears in 1 contract
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below: Patient’s Initials:
Appears in 1 contract
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it if is signed (including, but not limited to, emergency treatment) patient should initial below:
Appears in 1 contract
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here.
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, to emergency treatment) patient should initial below:.
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:: Effective as of the date of first medial services
Appears in 1 contract
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:: Effective as of the date of first medical services Client Initials
Appears in 1 contract
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient ), Patient should initial below:
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If patient intends this agreement Agreement to cover services rendered before the date it is signed (includinginc luding, but not limited to, emergency treatment) patient should initial below:;
Appears in 1 contract
Retroactive Effect. If a patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, to emergency treatmentsurgery) patient should initial below:
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, including but not limited to, emergency treatment) patient should initial below:here: Submit Form
Appears in 1 contract
Retroactive Effect. If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here _.
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If patient intends this agreement to cover services rendered before the date that it is signed (including, but not limited tofor example, emergency treatment) ), patient should initial below:here . Effective as of the date of first professional services.
Appears in 1 contract
Samples: Arbitration Agreement
Retroactive Effect. If a patient intends this agreement to cover services rendered before the date it is signed (including, but not limited tofor example, emergency treatment) patient should initial below:here: _____. Effective as the date of first professional services.
Appears in 1 contract
Samples: Arbitration Agreement