Medicaid Inactive Form Patient Details

Medicaid Inactive Form Contact Information

Medicaid Inactive Form MA Form

As we are a participating provider with Medical Assistance we are notifying you that according to the Electronic Verification system, or MN-ITS, your Medical Assistance is no longer valid. This notification will allow us to financially liable for the services listed below:

Service Total is unknown until after your visit.

Your signature on this waiver serves as an authorization to hold you financially liable for the above named patient for the above named services, in the event that your insurance is not reinstated.

Dakota Child and Family Clinic

(Please click below to draw/upload sign)
(Your IP Address :IP: )