Konsanman pou tretman’w

Broward Community & Family Health Centers, Inc.

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Avek ako moun ki malad la ak, otorizatyon moun ki resposab la/ konsantman moun ki avek malad la, broward community & family health centers,inc.,sant pou fasilite tretman ,ak tout dokte, dantis,chirijyen ak tout lot moun kap travay nan domen medical,gen otorizatyon pou yo pefome avek tout fom ekzamen medikal ak tretman ki nesese pou swen malad la pandan pandan pasyan ap kontinye dako poul swiv tretman li nan broward community& family health centers,inc.,ak tout pesonel medikal ki an ako avek li ,san malad la pap kontraye avek medikaman yap ba li pou tretman li.

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Malad la/moun ki ap okipe malad la*

Ki relasyon ou avek moun ki malad*

Dat*

Chwazi el sit de atansyon primè*

Imel*

Telefòn*

METOD KE OU KAPAB PEYE

Pa ki mwayen ou gen entansyon peye pou tretman ou?*

Map peye

Mwen gen medicare

Asirans prive

lot fason (ki fason li ye)

AKÒ

1st agreement*

Mwen dako poum responsab peye tout lajan swen medical mwen koutem nan broward community & family health centers,inc.sant pou fasilite tretman avek tout asosyel yo.si mwen gen yon asirans prive mwen dako poum peye sa mwen gen poum peye ak tout lot fre ke sa ap koutem.

2nd agreement*

Asirans medicare kouvrim.mwen dako poum resposab peye posyon pam nan e 20% medicare di poum peye a.mwen dako poum peye tout ti chaj siplemanteak tout lot ti fre ke sa ap koutem.

Avek siyati mwen:

Mwen otorize pou yo remet nenpot enfomasyon medical tankou,rezilta tes VIH(SIDA),maladi mantal,ect..ak tout rezilta ki nesese pou pwosesis demand asirans pou lasante kom medicare,Medicaid,konpayi asirans pou dokte,ak tout lot kote ki fasilite swen pou lasante malad yo.mwen dako tou poum remet Broward Community & Family Health Centers, Inc. sant pou fasilite tretman ak tout legal asosye responsab pesonel li yo ki ka inteveni,tout dosiem yo e mwen gen poum rete konfidan avek yo.
Mwen otorize Broward Community & Family Health Centers ak tout asosyel yo pou yo verifye infomasyon mwen nan men patwon’m.
Mwen otorize peye Broward Community & Family Health centers ak tout asosyel yo direkteman tout benefis medikal yo.

Non konplè*

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Broward Community & Family Health Centers, Inc.