Treatment/Payment Agreement Form – Medical

  • I request NATIVE HEALTH provide me and/or my family with medical, dental or behavioral health care. I acknowledge my responsibilities to pay for the care according to the fees established. Furthermore, I authorize assignment of insurance/benefits for medical, dental or behavioral health services to be paid to NATIVE HEALTH. By signing below I also acknowledge I have received a copy and explanation of the Health Insurance Portability and Accountability Act Privacy Rule.

    BY SIGNING THIS AGREEMENT, I ATTEST THAT ALL INFORMATION PROVIDED DURING REGISTRATION IS TRUE TO THE BEST OF MY KNOWLEDGE.

    Further, I understand that I am responsible for payment of any services I request for myself/family that are not covered by my insurance/benefits package or do not have health insurance.

    NATIVE HEALTH reserves the right to collect any unpaid amounts.

    BY SIGNING THIS AGREEMENT, I ATTEST THAT ALL INFORMATION PROVIDED DURING REGISTRATION IS TRUE TO THE BEST OF MY KNOWLEDGE.

    Front Desk Representative Signature:

    Signature:
    Print Name:

    FOR MINORS (under age 18):

  • Patient/Guardian Signature

  • Date Format: MM slash DD slash YYYY