TERMS & CONDITIONS
Consent to Treat: I authorize Phillips County Health Department (PCHD) to administer treatment as deemed necessary for care of the patient named above. I certify that I am the parent or legal guardian of the patient. I also certify that no guarantee or assurance has been made as to the results that may be obtained from the treatment.
Assignment of Benefits: All professional services renderd are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. The patient/parent/responsible party is responsible for any unpaid balances. Co-payments will be made at the time of of service. I request that payment of authorized Medicare, Medicaid or Other insurance company benefits be made to PCHD for any services furnished to me by PCHD. Regulations pertaining to Medicare and Medicaid assignment of both benefits apply. My signature indicates all information provided is true and correct.
Consent for Inclusion in MT's Statewide Immunization Information System (IIS): I authorize PCHD to collect and enter my or my child's immunization records into the Department of Public Health and Human Services' IIS. The IIS is a confidential, computer system that contains immunization records. I understand that information in the registry may be released to the public health agency as well as my or my child's health care providers to assits in my or my child's medical care and treatment. In addition, information may be relased to child care facilities and schools in which my child is enrolled to comply with state immunization requiremnets. I understand that I can revoke this authorization and have my or my child's record removed at any time by contacting my local health department.