CENA REHAB CENTER INITIAL PATIENT INTAKE FORM

Thank you for choosing CENA Rehab Center. Please fill in the information below.

Patient Information

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Referred Physician *

INSURANCE / ATTORNEY INFORMATION

LISTED DRIVER? *
I AUTHORIZE CENA REHAB CENTERTO RECEIVE AND SEND INFORMATION, TO MY INSURANCE CARRIER. I HEREBY AUTHORIZE PAYMENTS FROM MY INSURANCE COMPANY TO BE DIRECTED TO CENA REHAB CENTER. IF MY BENEFITS ARE EXHAUSTED DUE TO PRIOR HOSPITAL/ER/AMBULANCE/ETC I WILL NOTIFY THE BILLING DEPT OF CENA REHAB CENTER/ I AM RESPONSIBLE FOR ALL THERAPY BILLS BILLED BY CENA REHAB CENTER FOR SERVICES RENDERED TO ME BEYOND MY COVERAGE ALLOWABLE.
 
I UNDERSTAND FAILURE TO DO SO WILL PUT ME IN CHARGE/PERSONALLY RESPONSIBLE FOR ALL PAYMENT MATTERS FOR THE SERVICES CONDUCTED AT CENA REHAB CENTER. IF FOR ANY REASON(S) I DO NOT PAYFOR MY SERVICES I AUTHORIZE CENA REHAB CENTER TO FILE SUIT AGAINST ME AND I AGREE TO PAY ATTORNEY FEES AND CHARGES.
PATIENT'S SIGNATURE *
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