Dakota Child and Family Clinic-Medicaid Inactive Form

Medicaid Inactive Form Patient Details

First Name*

Last Name*

Middle Name

City*

State*

Zip*

Date of Birth*

Address*

Gender*

Marital Status*

Social Security Number

Driving License Number

Medicaid Inactive Form Contact Information

Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Extension Number

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we are notifying you that according to the Electronic Verification system, or MN-ITS, your Medical Assistance is no longer valid.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:

Date of Service*

Total Cost for the Above Date of Service

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

SIGNATURE (Patient/Parent/Guardian Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:3.237.66.86 )

Medicaid Inactive Form Patient Details

Medicaid Inactive Form Contact Information

Medicaid Inactive Form MA Form

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