Community Bridges Integrated Healthcare IPA

P.O. Box 489
Linden, Michigan 48451

989-673-0031

Patient Discount and Referral Program

Patients Name_________________________________________________

Address______________________________________________________

City______________________ State___________________ Zip Code ______________

Telephone________________________ E-mail________________________________

I understand there is no cost to me the patient for providing the referral to a discount practitioner, and/or service. Community Bridges Integrated Healthcare IPA if applicable will provide you with a referral to a discounted provider, however makes no guarantee of the charge for service or that the practitioner or service will honor the discount. Community Bridges Integrated Healthcare IPA assumes no liability for any claims related to care or delays in treatment.

By submitting your application for the discount program you agree to hold Community Bridges Integrated Healthcare harmless for any acts or omissions or injuries that you may sustain .

Patients Signature Agreement

I am over 18 years old______________________________________________

Date_____________________________________________________________

Please refer me to a____Family Physician _____A specialist please list type______________________________________________________

________Chiropractor _______Massage Therapist

_______Naturopathic Doctor/Herbal Healer

________Home Care ________Medical Equipment _________

___________Other

I have insurance____________ I do not have insurance_________

I want help finding a low cost provider___________

Fax to: 989-672-2483