GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HUMAN SERVICES
REHABILITATION SERVICES ADMINISTRATION
CLIENT SERVICES DIVISION
810 First Street, N.E., 9th Floor
Washington, DC 20002-2247
Telephone: (202) 442-8400
CLIENT RIGHTS AND RESPONSIBILITIES
My signature indicates that the rights and responsibilities in relation to rehabilitation services, as outlined above, have been discussed with me and a copy of this statement has been presented to me.
METHOD: Read by client
This is to certify that the information provided on the HEALTH CARE CHECKLIST is accurate.
Client Signature: /s/____________________
Gary Freedman
Employee Signature: /s/_____________________
Eugene Weatherford
Date: 3-7-06_________________
2005-09-07
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