Emergency Contact Information
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize R&R
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
ACKNOWLEDGEMENT: I hereby acknowledge that I have received, read and
TREATMENT CONSENT: I hereby request physical, occupational and/or speech
by the licensed clinicians at R&R
Rehabilitation. I authorize the clinicians to perform any and all forms of treatment,
therapy that may be indicated.