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CSBS/HIDC NEW PATIENT REGISTRATION
I certify that the above information is a true and complete statement of my financial and insurance situation to the best of my knowledge. I understand that the information I have given is subject to verification by Health and Infectious Disease Care(HIDC), and every effort will be made to keep my information private and confidential. I also understand that I may request a review of the charge(s) if I feel it is inaccurate. For family planning and communicable disease services, I understand that I will not be denied service(s) because of inability to pay.
I consent to entering into a client-provider relationship. I authorize Cadet Solutions DBA Health and Infectious Disease Care (HIDC)
staff and their representatives to render routine health care. I understand routine healthcare is confidential and voluntary and may involve medical office visits including obtaining medical history, examination, administration of medication, laboratory tests and/or minor procedures. I may discontinue the relationship at any time.
