OMHC/IOP SIGNATURE PAGE

OMHC/IOP SIGNATURE PAGE
Clinician/Practitioner Attestation: I attest I have completed a comprehensive treatment plan in our Electronic Medical Records (EMR) in lue of a table or signature pad am obtaining signatures for the medical or behavior health individualized plan dated for:
Print Person/Title of Person Completing the Document:
Signature

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Client Attestation:
Patient Fees and Charges

I authorize Changing Lives Adult & Youth Services to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage. By signing below, I am indicating that the information I have provided is accurate and to the best of my knowledge.
I, First Name* Last Name* confirm and agree with my involvement with the development of my person-centered Rehabilitation Plan. I understand that I have the choice of service providers and may change service providers by contacting the person for this IRP.
Client Signature (Age 9+) :*

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Date:*

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Parent/Guardian Printed Name:
Signature (If Applicable):

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Date:

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Should be Empty: