GENERAL CONSENT FOR INSURANCE, DIAGNOSIS, AND TREATMENT
I, the patient or parent / guarantor, hereby authorize any holder of information about me or any information needed for settlement of claims to be released to Medicaid, Medicare, or Insurance Provider. I understand approved claims will be deducted from my allocated benefits whether they were rendered in one our clinics or mobile health family.
I request that all health insurance benefit payments be made on my behalf to Jackson-Hinds Comprehensive Health Center. Having registered with JHCHC, I, the undersigned patient or responsible person, understand that this registration form is valid and services will continue as long as I or my child is enrolled in this school or until I decide to opt-out by sending a written notice to discontinue services.
My signature is my authorization to bill on my behalf. My signature also serves as authorization for service and treatment. I may provide a written notice to dismiss this authorization to Jackson-Hinds at any time.