Consent to Treat and Health Care AgreementConsent to Treat and Health Care Agreement • February 25th, 2016
Consent to Treat and Health Care AgreementConsent to Treat and Health Care Agreement • August 30th, 2016
Consent to Treat and Health Care AgreementConsent to Treat and Health Care Agreement • March 28th, 2016
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.
Consent to Treat and Health Care AgreementConsent to Treat and Health Care Agreement • 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.
Consent to Treat and Health Care AgreementConsent to Treat and Health Care Agreement • August 21st, 2013
Consent to Treat and Health Care AgreementConsent to Treat and Health Care Agreement • August 26th, 2023
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.
