Client Name:
Medicaid/Insurance ID#:
DOB:
Phoenix Preferred Care
Permission for Treatment
Permission is hereby given to the staff of Phoenix Preferred Care, Inc to render treatment, evaluate and/or provide service to:
Client Name
Whose relationship to me is:
Please Select
Self
Child
Spouse
Other
If other, please specify:
Signature
Date
/
Month
/
Day
Year
Date
PPC Representative
Date
/
Month
/
Day
Year
Date
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