I request that payment of authorized Medicare benefits be made either to me or on my behalf to Kingston Physical-Occupational Therapy and Sports Rehab, P.L.L.C. for services furnished to me by the by the Provider. I authorize any holder of medical information about me to release to the Health Care Financing administration and its agents any information needed to determine these benefits or the benefits payable for related services.

Signature is required.
reCAPTCHA is required.