Consent to Treat and Health Care AgreementNovember 20th, 2020
FiledNovember 20th, 2020If I am eligible for healthcare benefits under any federal or state program, including, but not limited to Medicare or Medicaid, I certify that the information given by me in applying for payment under any such programs is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or contractors any information needed for any federal or state program related claims.
Consent to Treat and Health Care AgreementMay 18th, 2015
FiledMay 18th, 2015if I am eligible for healthcare benefits under any federal or state program, including, but not limited to Medicare or Medicaid, I certify that the information given by me in applying for payment under any such programs is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or contractors any information needed for any federal or state program related claims.