Jackson County Public Health (JCPH) is managed and operated by University Health (UH).
Personal Financial Responsibility: By signing this form and in return for the services rendered by JCPH, UH and the Physicians, I am personally responsible for all UH fees and physician fees not paid by any third party on my behalf.
Assignment of Insurance Benefits: I hereby assign all my interest and rights to all insurance benefits, otherwise payable to me from any policy of insurance issued in my name or on my behalf, to JCPH, UH, UH physicians and/or University Physician Associates. I agree that UH and/or physicians may disclose any portion of my medical, financial or personal information to any person or organization requiring such information as a condition of paying, receiving payment for or justifying payment for my health care or the health care of one for whom I am responsible. I further authorize payment of all insurance benefits, otherwise payable to me, for all treatment provided directly to Jackson County Public Health, University Health, and/or University Physician Associates.
The notice of privacy practices can be found here: https://res.cloudinary.com/dpmykpsih/image/upload/truman-site-261/media/a9e26969dc2448bfa6552be9f828a139/uh_notice-of-privacy-practices_poster_2021.pdf
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