Examples of Patient Signature in a sentence
I agree that all information provided above by me in the claim documents is true and that if I have provided any false or untrue information, my right to claim the reimbursement of expenses shall be absolutely forfeited.Name of Patient / Relative: Relationship with Patient: Signature of Patient / Relative Date: DD / MM / YYYYPlease attach this form in Original to the hospital bill and other claim documents.
Signature: Patient Signature: Authorized Healthcare Professional obtaining and witnessing patient’s signature Signature: Attending physician (if applicable) Date: Time Date: Time Date: Time To be used if the patient is a minor, unconscious, or otherwise lacking decision making capacity.
Patient Print Name Patient Signature Date Responsible Party Print Name (if not patient) Responsible Party Signature (if not patient) Date Important Note Regarding After Hours/Weekend Services Relievus provides care for chronic problems.
Patient Name (printed) Date Patient Signature (18yrs and older) Parent/Guardian Signature (if applicable) Patient Responsibility Agreement & Therapy Terms/Conditions I, as myself, or as a representative for my child would like to pursue all means necessary to obtain speech/language/feeding services for myself/my child.
Patient Name Patient Signature Insurance Company Date No Insurance: If you do not have health insurance, have out-of-network coverage, or decide to OPT OUT of using your health insurance policy, you will be responsible for payment of our regular office fees at time of service.