If I’m feeling unsafe, I will go to the ER of local hospital, call Suicide Hotline 1-800-273-8255, or call my county’s crisis number.
(If patient is a minor (ages 14-18) he/she must sign this Registration-Assignment/Release/Consent to Treatment)
I certify that this data is true, correct & accurate. I understand that payment of this claim will be from federal & state funds. Any false claims, documents, or concealment of material facts may be prosecuted under applicable laws. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.