Attorney Information

Workers Compensation Attorney: ___________________________________________

Attorney Address: _______________________________________________________

City: ___________________________ State: ____________ Zip Code: ____________

Phone: (______)__________________

Billing

 

I authorize payment of benefits as determined by the insurance company directly to the Center for Physical Rehabilitation, Inc. I understand that I am responsible for this account if controverted by the Workers Compensation Insurance Carrier.

 

Patient Signature: __________________________ Date: ________________________

Medical Records

 

I authorize the Center for Physical Rehabilitation, Inc. to release any information requested with regard to this injury/illness and the expenses reported regarding my treatment.

 

Patient Signature: ___________________________ Date: _______________________