Treatment/Payment Agreement Form – Behavioral Health

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.
Patient Name
Patient/Guardian Signature
First Name*
Last Name*
Email*
Date*
MM slash DD slash YYYY
Front Desk Representative Signature:

Signature:

Print Name:

FOR MINORS (under age 18):
Comments
This field is for validation purposes and should be left unchanged.