Certificate Of Eligibility - Division Of Policy And Shortage Designation Bureau Of Health Workforce, Health Resources Services Administration Page 3

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When signing this form, you are agreeing to:
A. Not deny requested health care services, and shall not discriminate in the provision
of services to an individual because:
* The individual is unable to pay for the services, or
* Because payment for services would be made under: the Medicare program
(Title XVIII for the Social Security Act), the Medicaid program (Title XIX of
such Act), or the SCHIP (Title XXI of such Act).
B. Prepare a schedule of fees or payments for services, consistent with locally
prevailing rates or charges for health care services and designed to cover the
reasonable cost of operation.
C. Prepare a corresponding schedule of discounts (including, in appropriate cases,
waivers) to be applied to such fees and payments. Discounts shall be adjusted on
the basis of the patient's inability to pay.
D. Make every reasonable effort to secure from patients fees and payments for services
in accordance with such schedules, and fee or payments shall be sufficiently
discounted in accordance with C above.
E. Accept assignment for individuals who are beneficiaries under Medicare.
F. Enter into an appropriate agreement with the state agencies administering Medicaid
and SCHIP for individuals who are beneficiaries under those payments.
G. Take reasonable and appropriate steps to collect all payments due for health care
services provided by the entity, including payments from any third party.
H. Display prominently a notice of the availability of discounted fees and acceptance
of Medicare, Medicaid, and SCHIP to assure public awareness of these options.
These requirements are subject to review as part of the regular Rural Health Clinic Certification
process.

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