Thursday, February 02, 2012

D.C. Rehabilitation Services Administration -- Registration

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

Page 3 of 3

1 comment:

Gary Freedman said...

I have omitted the text of the CLIENT RIGHTS AND RESPONSIBILITIES Statement.