Patient Attestation:
I attest that all the information that I have provided to determine my eligibility for financial assistance for doula services is complete and correct to the best of my knowledge. I understand that I cannot request reimbursement for any services rendered through the doula access program from any government program or third-party insurer. I further agree to notify the doula of any changes in my income or insurance, or other factors used to determine my eligibility status were I to receive financial assistance in the future. I authorize the release of my Protected Health Information (PHI) for this patient assistance program or any third parties retained to administer the program and who may audit my PHI for the purpose of verifying my eligibility.