Patient Registration Information and Guarantor Agreement Sample Contracts

Contract

Patient Registration Information and Guarantor Agreement • August 14th, 2017

• Contract Type
  Patient Registration Information and Guarantor Agreement
• Filed
  August 14th, 2017

If the parents of the minor patient are divorced and custody is “Joint Legal,” both parents need to sign the Consent for Treatment. However, if parents are divorced and only one parent signs the Consent for Treatment, a copy of the custody agreement must be provided to PATH Group of Atlanta, LLC at the initial appointment. This agreement must reflect which parent obtains authority over medical decision-making.

Contract

Patient Registration Information and Guarantor Agreement • June 18th, 2017

• Contract Type
  Patient Registration Information and Guarantor Agreement
• Filed
  June 18th, 2017

Date of Birth Gender: M F Marital Status Street Address City/State/Zip Cell Phone Home/Work Phone (please circle one) Email Referred by Family Physician Phone number Pharmacy Name and Phone Number Emergency Contact