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FINANCIAL ASSISTANCE/ MEDICAL HARDSHIP APPLICATION

WEBForm Updated 12-16-19 Page 4 of 4 PATIENT AUTHORIZATION I allow my doctor(s), any health care providers, the patient financial assistance advocate, and my

Actived: 6 days ago

URL: https://greeley.health/wp-content/uploads/2022/07/Financial-Assistance-Application.pdf

2024 adult (19 and up) registration form

WEBGreeleyCountyHealthServices ServewithCompassion&Excellence REGISTRATIONFORM(AGE19ANDUP) Patient’sName_____Birthdate_____ …

Category:  Health Go Health

PIATE HEATH INFOMATION

WEBev 3/2024 Kansas State High School Activities Association | 601 SW Commerce Place | Topeka, KS 66615 | 785-273-5329 6 PIATE HEATH INFOMATION - KEEP CONFIENTIA

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Consent for Treatment of a Minor Without Parent Present

WEBGreeleyCountyHealthServices ServewithCompassion&Excellence ConsentforTreatmentofaMinorWithoutParentPresent

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Understanding Healthcare Prices: A Consumer Guide

WEBUNDERSTANDING HEALTHCARE PRICES: A CONSUMER GUIDE 3 I f you’re like many Americans, you don’t know what an emergency department visit or an operation costs …

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Greeley County Health Services Patient Financial Assistance …

WEB2.6 Income is defined as adjusted gross income (AGI) plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest. 2.7 Family size is …

Category:  Health Go Health

Presumptive Eligibility for Pregnant Women

WEB3 4 . 6 . 7 . 8 Extra Person . Income . 2810 . 3543 4275 . 5007 5740 . 6472 . 7205 732

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Adult Health History Form

WEBGreeleyCountyHealthServices ServewithCompassion&Excellence MEDICALHISTORY: Pleasecircleallthatapply General Chills Fatigue Fever NightSweats SleepDifficulties …

Category:  Medical Go Health

matching Funds your Dollar matching Dollar Twice the …

WEBmatching Funds your Dollar matching Dollar Twice the Impact!! Greeley-Wallace County Healthcare Foundation Looking for a great way to increase the impact of

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Copy of Pediatric Health History Form

WEBGreeleyCountyHealthServices ServewithCompassion&Excellence MEDICALHISTORY: Pleasecircleallthatapply General Chills Fatigue Fever NightSweats SleepDifficulties …

Category:  Medical Go Health

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