ࡱ > 7 bjbjUU , 7| 7| l X X X X X X X 8 r " 8 8 8 8 $ b Z X X X 8 8 , | X 8 X 8 6 X X 8 }l( 2 B 0 r l ~ X X X X EMBED PBrush VANITAS REHAB 31 NELSON AVENUE, MELBOURNE, FL 32935 Website: www.vanitasrehab.com Phone: 321-432 5573 Fax: 321-726 9938 Authorization For Medical Treatment/Physical Therapy By signing in the space provided as Patient/Surrogate/Guardian/Spouse, I hereby agree and give my consent for the Physical Therapist/Assistant at Vanitas Rehab to furnish the physical therapy care and treatment deemed by the Physician, Physical Therapist/Assistant, or other provider to be necessary and proper in evaluating and healing my/their physical condition. Signature: ___________________________ Date:_________________ Authorization To Release Benefit Information I hereby authorize and request ___________________________ (Insurance Company) to release All benefit information to Vanitas Rehab. Patient Name: _________________________ Claim # (if applicable): _____________________ Date of Accident (if applicable): __________ Signature: ___________________________ Date:_________________ Authorization To Release Medical Records I hereby authorize Vanitas Rehab, or other medical representatives who have attended to me to furnish my insurance company (ies) listed above or their representatives with any and all information that may be contained in their medical records. Signature: ___________________________ Date:_________________ Assignment of Insurance Benefits I hereby authorize payment directly to Vanitas Rehab of the physicians benefits otherwise payable to me by my insurance. I understand that Vanitas Rehab is not responsible for the terms of the Contract(s) which I have with my Insurance Company (ies), which may determine to pay all, some, or none of the charges resulting from my medical care. I also understand that I am financially responsible to Vanitas Rehab for charges/benefits not covered by my insurance and promise to pay immediately on demand. I hereby certify that I am NOT under Home Health Care (Please note you will be personally responsible for payment for this service if this turns out not to be true, as insurance will deny claims). I agree to pay $50 appointment cancellation fee if I cancel my appointment without giving 24 hour notice. Signature: ___________________________ Date:_________________ Tel: _____________________ e-mail: __________________________ " # T ~ ( 55\ OJ QJ ^J >*OJ QJ ^J CJ jaD UV j U # 6 K i M N = h S T } ~ s t ! $a$ t + , ! $a$ $ ! a$ * 0 0 1 / =!"#`$% D d *Q 0 # A b G ::Ir\lۿ"o # D n ::Ir\lۿ"oPNG IHDR 5 6 F sRGB pHYs j IDAThCy[yx A6;L7g3ًV,Y*|)YQJUJ<%TؕJŖ,J]ڕٝKOO_9}a H vMʉ@{XSA[G.aa[U"J2CcPD~BDOA y}mS`Ep1BHA̧Q˦_AoZUXX(cE 4X.b5dl+ \[h!>5˸,E)e t YA1XI h{N" ?W1&25M !F!aUOό VC'5Utb tf;(2Y#$х/|D B@Aᨄ؏ ;UBRՆ4"c (|HyϨ>knMDL X%L!Nf\tx"\t0 vkA8}cR 抪_:/`!<1T;$ !q58Y+Ӥcn췜̛!1Аcƨp=Krd"ońb%a\RqAJTy>ΞN KZvFH{gvVY+vE !Asle8cSUQHrNÝC4#1e%