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NHI Registration
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Social Security Number
*
Name
*
First
Middle
Last
Date of Birth
*
Gender
*
Male
Female
District
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Village/Town/City
*
Area
Phone
*
Email
*
Employer
18 yrs or Older
*
Yes
No
Patient Contact Number
or Birth 18
NHI Transfer Agreement
1. I understand that I am allowed only one transfer per calendar year.
2. I confirm that I have not transferred to another clinic within the past 12 months.
3. I hereby provide a valid reason for my transfer request.
4. I understand that this transfer may affect my current care arrangements and that it is my responsibility to ensure continuity of care.
5. I authorize the release of my medical records from my current PCP to the new PCP to ensure continuity of care.
6. I understand that this transfer is subject to approval and processing by the relevant health authorities.
By signing below, I certify that I have read, understood, and agree to the terms outlined in this consent form.
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