Form Completion. There will be a $25.00 fee for all insurance and disability forms needing to be filled out by the physician. Due to safety concerns, children are NOT permitted into the examination areas. Children must be accompanied and supervised by an adult at all times. NO EXCEPTIONS We reserve the right to reschedule your appointment if necessary. Date Injury Occurred: / / Time of Injury: Time Arrived at Clinic: Did your employer authorize your visit today? □ Yes □ No Name:
Appears in 2 contracts
Sources: Financial Agreement and Assignment of Benefits, Financial Agreement and Assignment of Benefits