Please read the statements below:
A) I have personally supplied and reviewed the information on this form and attest it is true and complete, to the best of my knowledge. I understand the information is strictly confidential and will not be released to anyone without my written consent, or as otherwise permitted by law. If I should be ill, injured, or otherwise unable to sign the appropriate forms, I hereby give my permission to the institution to release information from this form to a physician, hospital, or medical professional involved in providing me with emergency treatment and/or medical care.
B) I hereby authorize any medical treatment for myself that may be advised or recommended by the Director of Medical Services.
C) I am aware I may be charged for some health services provided by the University and I may be billed through the University Business Office, if the account is not paid at the time of the visit. I accept personal responsibility for settling the account with the University Business Office and for payment of incurred charges. I am responsible for filing outpatient charges with my insurance. I also acknowledge my responsibility to Mars Hill University is unaffected by the existence of insurance coverage.
CONTINUE BELOW TO SIGN THE ACKNOWLEDGEMENT