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Part 2, Chapter 4:  Manual Appendix A

Application for Treatment at Remote PHS Facility

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APPLICATION FOR TREATMENT AT REMOTE PHS FACILITY UNDER 42 U.S.C. §251
(Section 324 Partnership for Health Amendment)

I, ______________________________________
      (Name)

Address:______________________________________

Name & Address of Employer ____________________________________________________________________________

Employee Identification* ______________________________________

herby apply for medical care for:

Myself and/or My dependents as follows

(Use reverse side if additional space is needed.)

I understand that I will be charged for the care furnished, at the current Bureau of Budget rates, and that a false or fraudulent statement is punishable under [8 U.S.C.§100].

_____________________________________________
(Signed)

* Show credentials, government drivers license, building pass, employees' assn. or credit union membership card, and/or Social Security No., or certification by employing unit or official.