Common Contracts

3 similar Patient Agreement contracts

Contract
Patient Agreement • April 16th, 2004

PATIENT’S AGREEMENT WITH HOSPITAL IN RELATION TO A HOME OTHER THAN HIS OWN 1. NAME OF VA STATION 2. ADDRESS 3. TELEPHONE NO. 4. NAME OF VETERAN 5. SOCIAL SECURITY NO. 6. CLAIM NO. 7. AGREE TO PAY MONTHLY 8. NAME OF PAYEE 9. ADDRESS 10. TELEPHONE 11. NAME OF SOCIAL WORKER AGREEMENT: I agree to pay monthly the amount specified in Item No. 7 to the Payee named in Item No. 8 for room, board, laundry, and attention to my welfare. I further agree to discuss any matter of concern to me that arises during the course of this agreement with the Payee and with the Social Worker named above before I make any change in this agreement. 12. SIGNATURE OF VETERAN 13. DATE 14. SIGNATURE OF SOCIAL WORKER (WITNESS) 15. DATE

Contract
Patient Agreement • April 16th, 2004

PATIENT’S AGREEMENT WITH HOSPITAL IN RELATION TO A HOME OTHER THAN HIS OWN 1. NAME OF VA STATION 2. ADDRESS 3. TELEPHONE NO. 4. NAME OF VETERAN 5. SOCIAL SECURITY NO. 6. CLAIM NO. 7. AGREE TO PAY MONTHLY 8. NAME OF PAYEE 9. ADDRESS 10. TELEPHONE 11. NAME OF SOCIAL WORKER AGREEMENT: I agree to pay monthly the amount specified in Item No. 7 to the Payee named in Item No. 8 for room, board, laundry, and attention to my welfare. I further agree to discuss any matter of concern to me that arises during the course of this agreement with the Payee and with the Social Worker named above before I make any change in this agreement. 12. SIGNATURE OF VETERAN 13. DATE 14. SIGNATURE OF SOCIAL WORKER (WITNESS) 15. DATE

Contract
Patient Agreement • April 16th, 2004

PATIENT’S AGREEMENT WITH HOSPITAL IN RELATION TO A HOME OTHER THAN HIS OWN 1. NAME OF VA STATION 2. ADDRESS 3. TELEPHONE NO. 4. NAME OF VETERAN 5. SOCIAL SECURITY NO. 6. CLAIM NO. 7. AGREE TO PAY MONTHLY 8. NAME OF PAYEE 9. ADDRESS 10. TELEPHONE 11. NAME OF SOCIAL WORKER AGREEMENT: I agree to pay monthly the amount specified in Item No. 7 to the Payee named in Item No. 8 for room, board, laundry, and attention to my welfare. I further agree to discuss any matter of concern to me that arises during the course of this agreement with the Payee and with the Social Worker named above before I make any change in this agreement. 12. SIGNATURE OF VETERAN 13. DATE 14. SIGNATURE OF SOCIAL WORKER (WITNESS) 15. DATE