Common Contracts

2 similar null contracts

Consent to Treat and Health Care Agreement
November 20th, 2020
  • Filed
    November 20th, 2020

If 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.

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Consent to Treat and Health Care Agreement
May 18th, 2015
  • Filed
    May 18th, 2015

if 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.

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