Consent to Treat

Horizon
give permission for Horizon Health Services LLC.

2.2) I allow Horizon Health Services LLC. to file for insurance benefits to pay for the care

Horizon Health Services LLC. will have to send my medical record information to my insurance
Patient or Parent/Guardian Signature Date

Clear
Printed Name
I must pay my share of the costs.

I must pay for the cost of these services if my insurance does not pay or if I don't have insurance.

I have the right to refuse any procedure or treatment.

I have the right to discuss all of my medical treatments with my clinician.
Should be Empty:

Horizon