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Medical Information

Self Pay TRICARE Auto Insurance Medicare Other Insurance Legal
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Active Duty Retired Standard
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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.

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