I, , hereby authorize Rehab At Work to apply for benefits on my behalf for covered services rendered by Rehab At Work and request that the payments from be made directly to the Rehab At Work. I certify that the information I have reported, with regard to my insurance coverage, is correct and further authorize the release of any necessary information, including medical information for this or any related claim, to my insurance carrier, referring physician, rehabilitation nurse, attorney and /or others in order to determine benefits to which I may be entitled. I permit a copy of this authorization to be used in place of the original.

This is to certify I, the undersigned, do hereby voluntarily consent to the administration of outpatient care including tests, examinations, and treatment as may be considered necessary or advisable.

SIGNATURE:_______________________________ DATE:___________________