PATIENT ATTESTATION AND AGREEMENT
Please provide your date of birth for identification purposes.
Only Applicants 18 years or older are eligible.
By electronically signing below:
I pledge all information provided to Lackey Clinic for the purpose of my patient application or recertification is true to the best of my knowledge. I understand this information may need to be verified and that withholding information or giving false information will make me ineligible for care.
I understand if my income changes or if I become insured, including through Medicaid and Medicare, I must notify the clinic of these changes immediately. I understand any falsification or witholding of information regarding income or insurance status will result in suspension or dismissal from the clinic.
I understand if I become or continue to be a Lackey Clinic Patient, I am responsible for renewing my Lackey Clinic Patient status. I understand I will not be able to receive care or medications if my Lackey Clinic Patient Status is expired.
I understand if I become or continue to be a Lackey Clinic Patient, I am required to bring in my 1040 (tax statements) immediately after filing and will not wait until my next recertification.
I consent to necessary treatment, laboratory test(s), and consultations recommended by my medical and/or dental team as needed for my health if I become or continue to be a Lackey Clinic Patient.
I authorize my medical and financial information to be shared with other health care providers, pharmaceutical companies, and RXPartnership, including their designees, as needed for audit or medical/dental treatment purposes if I become or continue to be a Lackey Clinic Patient.
I understand if I become or continue to be a Lackey Clinic Medical Patient, additional documentation may be requested as needed when ordering medication.
I authorize LMAP (Lackey Medication Assistance Program) caseworkers to become my advocate in ordering medications if I become or continue to be a Lackey Clinic Medical Patient. In doing so, I authorize them to sign the application forms and reorder medications as needed on my behalf.
I understand if I become or continue to be a Lackey Clinic Dental Only Patient, I will only be eligible to be seen by the Lackey Clinic Dental Department. I understand that I am not eligible for medical services or medications provided by Lackey Clinic.
Disclaimer for Medicaid eligible patients:
Please be advised, because of the restrictions given to us by other health care providers and pharmaceutical companies, patients who are currently uninsured but may be eligible for Medicaid may receive limited services. These services include but are not limited to: specialty care, surgeries, and certain medications.
Disclaimer for undocumented patients:
Please be advised, because of restrictions given to us by other health care providers and pharmaceutical companies, undocumented patients may receive limited services. These services include but are not limited to: specialty care, surgeries, and certain medications. [Le informamos que como consecuencia a las restricciones impuestas a los servicios provistos a pacientes indocumentados, por proveedores y compañías farmacéuticas, usted podrá recibir únicamente servicios limitados en la Clínica de Lackey. Estos servicios limitados incluyen pero no se limitan a, cuidados especiales, cirugía y solo ciertos medicamentos.]
I understand that by typing my name in the below textbox and clicking "Submit", I am electronically signing this document.
Please type your first and last name into the textbox below as your electronic signature.
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