I hereby affirm that I have not received, nor have I been promised to receive, any payment,
cash, money, gift, kickback, or other consideration, directly or indirectly, from any person or company (including any home care company) in return for my requesting any item, good, or service for my medical treatment either by (1) Visiting Physicians of Detroit, PLLC or by (2) any other healthcare provider, for which payment may be received in whole or in part under a Federal health care program.


I acknowledge that:


I have read the above paragraph,


I have had an opportunity to ask any questions, and I have had my questions satisfactorily answered, and I understand the above paragraph