Rehabilitation Center VRC Payor Authorization Form

Applicant's Name: *

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Last

Applicant's Date of Birth:

Specific program goals:

Summary of previous vocational training:

Please list the desired vocational outcomes:

Please provide a baseline of current skills:

Please note any medical or health needs that may or will have a bearing on the applicant’s participation in the program. Please keep in mind the structure and content of the program as well as the ability to live and dine in the community:

Printed Name of VR Counselor/Authorized Payer:

Name as Signature: *

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Last

Checking this box indicates an electronic signature: *

Check to accept

Date: *