Medicaid Waiver - LCOH

I (or the patient named below) am eligible to receive health care benefits through Medicaid.

I understand that the care, treatment and services I seek for myself (or the patient named below) from the Lindner Center of HOPE might be Medicaid “covered services”. That means that benefits under the Medicaid program might be available to pay for some or all of the care, treatment and services sought.

I wish to assume financial responsibility for all charges associated with the care, treatment and services below:

As result of my decision to assume personal financial responsibility for care and treatment to be provided to me (or the patient named below), I acknowledge that the Center will not be able to bill the Medicaid program, and Center agrees not to bill any third-party, including the Ohio Department of Job and Family Services, or any other Federal or State agency involved in the administration of the Medicaid program within the State of Ohio.

Payment Responsibility: As result of my voluntary decision to waive any benefits or reimbursement that would otherwise be available through the Medicaid program for this care and treatment, I acknowledge that I am financially responsible for all charges associated with health care services provided by the Center to me (or the patient named below). I understand that payment for services is due at the time services are rendered unless special arrangements are made in advance.

I fully understand and agree to the Center’s policies and conditions described in this agreement. A copy of this agreement will be made available upon request.

Patient Name: