CONSENT for TREATMENT and PAYMENT
PATIENT NAME: ______________________________ SSN/SID#/Patient ID#:______________
Consent for Treatment:
I, being of legal age, hereby give consent and authorization for myself, my child, or legal ward to the physicians, professionals, and technical personnel of Coppin State University Community Health Center to perform any therapeutic and diagnostic procedures which in their judgment are necessary and desirable while a patient at this medical center.

Termination of Treatment:
I, hereby agree that if the patient leaves, the medical center without the consent of the physician and/ or fails to carry out the following care, these actions shall be at the patient's sole risk and the Health Center is removed from all responsibility, and agree to indemnify and protect the medical center from any connection with claim(s) whatsoever, that may arise.
Valuables Release:
The Health Center shall not be responsible for the loss of or damage to any personnel property of the patient brought into the Center.

Assignment of Benefits:
I authorize my insurance benefits be paid directly to the CSU Community Health Center. I understand that I am financially responsible for any balance. I also authorize CSU Community Health Center or insurance company to release any information required to process my claims.

Privacy Practices Acknowledgement:
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.
		
These statements indicated above have been explained or read to me; my signature indicates that I understand.

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   Witness (Office Staff Only)            Date        Signed (Patient or parent if minor)        Date

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  Telephone Consent given by            Date               Relationship to Patient