ContractRequest for Treatment • August 9th, 2023
REQUEST FOR TREATMENT. I acknowledge and agree that The Charlotte-Mecklenburg Hospital Authority d/b/a Atrium Health, Navicent Health, Inc. d/b/a Atrium Health Navicent, Floyd Healthcare Management Inc d/b/a Atrium Health Floyd, Wake Forest University Baptist Medical Center, and any affiliates and wholly owned subsidiaries of the foregoing (collectively “Atrium Health”) procures, contracts with, maintains or furnishes providers, personnel, equipment, supplies, transportation, facilities, drugs, tests and numerous other items and things in connection with and to provide me with medical care, diagnostics, and treatment (all such items, things, care and treatment being referred to collectively as the “Services,” whether provided by Atrium Health or another person or entity). Patient (or, if applicable, the responsible party/ies executing this Authorization below for patient) (with all responsible party/ies, when referring to consent, authorization, payment and other obligations and matter
