Patient Attestation of Self-Employment

Patient Attestation of Self-Employment
Name

First NameLast Name
Birth Date

MonthDayYear
Start Date of Self-Employment

MonthDayYear
Date
Location of Work
Type of Business/Work
Average Weekly Income
I confirm that I am currently self-employed, earning income through my own business, trade, or freelance work. I’ve provided the information below to the best of my ability and understand that additional documents may be requested to help verify my self-employment. I understand that it is my responsibility to notify the clinic if my self-employment income or financial circumstances change significantly.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: