This customizable document, Treatment Consent, Assignment of Benefits, Agreement to Pay and Release of Information Agreement Form, is taken from MCN Healthcare’s Home Infusion Therapy Policy and Procedure Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

Health care organizations around the world utilize MCN’s compliant ready templates and workflow process tools to help them meet the latest changes in regulations and standards.

Here is some sample content from Treatment Consent, Assignment of Benefits, Agreement to Pay and Release of Information Agreement Form:

	TREATMENT CONSENT, ASSIGNMENT OF BENEFITS, AGREEMENT TO PAY AND RELEASE OF INFORMATION AGREEMENT Client Name: This agreement is entered into by and between and the above named client or legal representative. This agreement is established in order to allow the client whose name is shown above, to obtain nursing care and other therapeutic services. It also serves to authorize to invoice available payment sources for those services provided and to permit the release of information from the client's records to insurers and others who may provide care for him/her in the future. Treatment...
Second excerpt:
	... A - Hospital q B - Medical Medicare # Confirmation: Client/responsible relative/agent confirms that he/she has read the foregoing information and has been given a copy of this form, stating that the client will abide by these arrangements and that all information given is correct. Client Signature or Signature of Individual Acting on Client's Behalf Relationship If client is unable to sign, explain why here. Agent Representative's Signature ?? ?? ?? ?? TREATMENT CONSENT,...