• (patient name) give permission for Restore Health KYto give me medical treatment
  • 2. I allow Restore Health KY to file for insurance benefits to pay for the care I receive.

              I understand that:

    • Restore Health KY will have to send my medical record information to my insurance company.
    • I must pay my share of the costs.
    • I must pay for the cost of these services if my insurance does not pay or I do not have insurance.

    3. I understand:

    • I have the right to refuse any procedure or treatment. 
    • I have the right to discuss all medical treatments with my clinician.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY