CONSENT TO TREAT - Suboxone Doctor Lexington Kentucky

I,*
First Last
(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.
Patient’s Signature*
Date*
MM slash DD slash YYYY
Parent or Guardian Signature (for children under 18)*
Date*
MM slash DD slash YYYY
Print name*
First Last