AUTHORIZATION FOR TREATMENT AND FINANCIAL AGREEMENTTreatment and Financial Agreement • December 13th, 2016
PATIENT CONSENT FOR TREATMENT AND FINANCIAL AGREEMENT HIPAA – DISCLOSURE OF PROTECTED MEDICAL INFORMATIONTreatment and Financial Agreement • April 23rd, 2021
Treatment and Financial AgreementTreatment and Financial Agreement • February 16th, 2023
Treatment: HUPTI accepts the patient named below for proton therapy treatment. The undersigned hereby consents to HUPTI providing and administering all services and supplies ordered by the patient’s attending physicians, and to the performance of all proton therapy procedures they deem advisable. I acknowledge that all medical treatment involves some risks and that no guarantee can be given regarding the outcome.
INTERMOUNTAIN EAR, NOSE & THROAT SPECIALISTS/ UTAH HEARING AND BALANCE CENTER PATIENT CONDITIONS OF TREATMENT AND FINANCIAL AGREEMENTTreatment and Financial Agreement • May 2nd, 2021
This document is an agreement between Intermountain Ear, Nose and Throat Specialists (or "IENT") and/or Utah Hearing and Balance Center (or "UHB") and the Patient and/or the Patient's Guarantor ("You"). In consideration of the health care services provided to you or the Patient and on all other accounts for future health care by IENT/UHB, you agree as follows:
