Health Information Sample Contracts

Participation Agreement

Health Information • July 26th, 2012 • Connecticut

• Contract Type
  Health Information
• Filed
  July 26th, 2012
• Jurisdiction
  Connecticut

PARTICIPANT NAME (a “Participant”) Address Contact Name(s) Telephone Number(s) Facsimile Number(s) Electronic Mail Address(es)

Consent to Use and Disclose Your Health Information

Health Information • December 12th, 2017

• Contract Type
  Health Information
• Filed
  December 12th, 2017

This form is an agreement between you, and Well Care Services. When we use the words “you” and “your” below, this can mean you, your child, a relative, or some other person if you have written his or her name here: