***PLEASE FILL OUT IF YOU ARE NOT THE PRIMARY CARD HOLDER***

I understand that as a condition to my receiving treatment, Baton Rouge Christian Counseling Center may use or disclose my personally identified health information for treatment,

The doctor may use my health care information and may disclose such information to the Insurance Company(ies) and agencies for the purpose of obtaining payment for services

By way of my signature, I provided Horizon Physical Therapy wit my authorization and consent to use and disclose my protected health information for the purpose of treatment,

I understand that Del Mar Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality

understand that Bay State Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality

I understand that NCEPT may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services

I understand that Think Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality

I understand that REHAB XCEL OF EUNICE, LLC may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating that quality