Common Contracts
1 similar null contracts
Consent and Service AgreementOctober 15th, 2020
Contact Information (Family, Guardian, or Legal Representative) NAME RELATIONSHIP TO RESIDENT HOME PHONE (WITH AREA CODE) WORK PHONE (INCLUDE AREA CODE) CELL PHONE (INCLUDE AREA CODE) PAGER ADDRESS EMAIL ADDRESS Private Insurance Information Complete the following if the resident has medical or dental insurance other than Medicare or Medicaid. Medical PRIMARY MEDICAL INSURANCE ADDRESS PHONE (INCLUDE AREA CODE) SUBSCRIBER’S NAME SUBSCRIBER NUMBER EMPLOYER NUMBER GROUP NUMBER Dental PRIMARY DENTAL INSURANCE ADDRESS PHONE (INCLUDE AREA CODE) SUBSCRIBER’S NAME SUBSCRIBER NUMBER EMPLOYER NUMBER GROUP NUMBER If the resident has secondary insurance, attach a separate sheet with the information required above. Service Agreement I voluntarily agree that the above named person (resident) receive services from the Residential Habilitation Center (RHC). I authorize the RHC to carry out the duties and responsibilities described in the individual habilitation plan or individual plan of care. I under
