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Gender at birth
1. Is this condition related to an injury on the job? (If yes please provide workers compensation information below)
2. Is this injury related to a Motor Vehicle Accident? (If yes, please provide your auto insurance information below)
3. Is this injury involved or will be involved in litigation? (If yes, please provide attorney information below)

I authorize P.E.A.C.H Rehabilitation and Wellness to release and request information to/from insurance companies and all medical providers. I authorize assignment of benefits directly to this clinic.

Thanks for submitting!

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