Insurance agreement form 2026

1. Click ‘Get Form’ to open the insurance agreement form in the editor.
2. Begin by entering the name of your clinic in the designated field at the top of the form. This identifies your organization as the Rural Health Clinic.
3. Review Section (A) regarding compliance with certification conditions. Ensure you understand these requirements, as they are crucial for maintaining eligibility.
4. In Section (B), confirm that you will not charge beneficiaries for covered services, except for applicable deductibles or coinsurance. Make sure to check this box if you agree.
5. For Section (C), indicate your commitment to refund any incorrectly collected payments promptly. This is essential for maintaining trust with beneficiaries.
6. Complete Sections (D) and (E) by affirming your acceptance of care provisions and any additional requirements set forth by the Secretary.
7. Finally, sign and date the form in the designated areas for both the Rural Health Clinic representative and the Secretary of Health and Human Services.

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