Emergency Contact Information
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize R&R
Rehabilitation to
release
any medical information necessary
to process insurance claims and hereby certify that the above information is correct.
AUTHORIZATION TO PAY BENEFITS: I hereby authorize payment of benefits
directly to R&R
Rehabilitation medical services
rendered. I FULLY UNDERSTAND THAT I AM RESPONSIBLE FOR ANY UNPAID BALANCE AND
HEREBY
AGREE
TO
PAY
SUCH BALANCE.
ACKNOWLEDGEMENT: I hereby acknowledge that I have received, read and
agree
to the
PATIENT
PAYMENT.
TREATMENT CONSENT: I hereby request physical, occupational and/or speech
therapy
treatment
by the licensed clinicians at R&R
Rehabilitation. I authorize the clinicians to perform any and all forms of treatment,
medication,
and
therapy that may be indicated.
