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  • No MCD Agreement

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    darrellcoleson1
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    This document is a notice from Cape Family Practice informing patients that if they are currently self-pay or using insurance but later obtain Medicaid, the practice may not accept Medicaid as payment for services rendered. The patient would need to go through the new patient procedure and may not be accepted into the practice. The document requires signatures from the patient, parent if a minor, and a witness.

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    No Mcd Agreement[1]

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    This document is a notice from Cape Family Practice informing patients that if they are currently self-pay or using insurance but later obtain Medicaid, the practice may not accept Medicaid as payment for services rendered. The patient would need to go through the new patient procedure and may not be accepted into the practice. The document requires signatures from the patient, parent if a minor, and a witness.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    6 views1 page

    No MCD Agreement

    Uploaded by

    darrellcoleson1
    This document is a notice from Cape Family Practice informing patients that if they are currently self-pay or using insurance but later obtain Medicaid, the practice may not accept Medicaid as payment for services rendered. The patient would need to go through the new patient procedure and may not be accepted into the practice. The document requires signatures from the patient, parent if a minor, and a witness.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    C Cape Family Practice

    FP Anthony J. Keele, MD 1417 N. Mount Auburn


    Lori A. Moyers, DO Cape Girardeau, MO 63701
    Keith W. VanCuran, MD (573)-334-6053
    www.capefamilypractice.com (573) 334-7855 (fax)

    I UNDERSTAND THAT I HAVE BEEN ACCEPTED AS A SELF-PAY OR


    INSURANCE-PAY PATIENT. I UNDERSTAND THAT IF I OBTAIN
    MEDICAID, IT MAY NOT BE ACCEPTED AS PAYMENT FOR SERVICES
    RENDERED. I WILL NEED TO GO THROUGH THE “ NEW PATIENT”
    PROCEDURE AND MAY NOT BE ACCEPTED INTO THE PRACTICE.

    __________________________ __________________________
    PATIENT SIGNATURE DATE

    ___________________________ _____________________________
    PARENT SIGNATURE DATE

    ___________________________
    ______________________________
    WITNESS SIGNATURE DATE

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