Get Dh 3204 11-08 Initiation Of Services

The DH 3204 11-08 Initiation Of Services form is an important document for establishing a client-provider relationship with the Florida Department of Health. This guide will assist you in filling out the form accurately and effectively online, ensuring all necessary information is provided for your healthcare needs.

Follow the steps to complete the DH 3204 11-08 Initiation Of Services successfully.

1. Press the ‘Get Form’ button to obtain the document and open it in your preferred online editor.
2. Begin by entering your full name in the designated field for 'Client Name.' Ensure that you provide your legal name as it appears on your identification.
3. In the 'Name of Agency' section, select 'Florida Department of Health-Hillsborough County' to confirm the agency you are engaging with.
4. Fill in the 'Agency Address' field with '8605 N. Mitchell Ave. Tampa, FL 33604' to provide the correct location of the service provider.
5. Review and consent to the client-provider relationship. This section allows you to authorize the department to provide routine health care services. It is essential that you understand this relationship is voluntary and confidential.
6. Navigate to the Disclosure of Information Consent section, where you will consent to the use of your medical information for treatment, payment, and healthcare operations.
7. If applicable, complete the Medicare Patient Certification section, certifying the information provided for Medicare claims is correct and authorizing the agency to release your medical information for this purpose.
8. If necessary, fill out the Assignment of Benefits section for those with third-party payers, assigning the benefits to the agency for the payment of medical services.
9. Sign the document in the 'My Signature Below Verifies' section to confirm the accuracy of the information and acknowledgment of privacy rights.
10. Indicate your relationship to the client in the designated field to clarify your role.
11. If a witness is available, they should also sign in the provided space, though this is optional.
12. Complete the date fields to document when the form is filled out.
13. If you wish to withdraw consent at any point, complete the provided section for withdrawal, ensuring to date and sign where indicated.
14. Finally, once you have filled out all necessary sections, you can save changes, download, print, or securely share the form as required.

Start filling out your DH 3204 11-08 Initiation Of Services form online today for seamless healthcare management.