Common Contracts
1 similar Consent and Service Agreement contracts
Consent and Service AgreementConsent and Service Agreement • June 5th, 2019
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 this document. I understand that I may end this agreement at any tim
