Registration and Forms – MAC Physical Medicine & Rehabilitation

To schedule a new client appointment, please call (734) 622-9500 or send an email to PMRinfo@MichiganAbilitiesCenter.org. Client intake forms are provided below.

Client Registration and Additional Forms

Client forms are provided below in PDF files. The PDF file can be opened using Adobe Reader, which may be downloaded free by clicking the link below.

Client Intake Welcome Letter & Forms

Client Welcome Letter
Client Registration Form
Client History Form
Notice of Privacy Practices
Consent for Treatment & Payment Agreement
Financial Responsibilities Policies & Insurance Authorization

Release of Information Forms

Release of Information (Generic)
Release of Information (for WSUPG)

Additional Forms for Auto No Fault Insurance Coverage

Insurance Assignment Authorization
Case Manager & Representation Information and Release

Please complete the above forms and bring the original forms to your appointment. If possible, also send the completed forms prior to your appointment by email or fax to:

Michigan Abilities Center Physical Medicine & Rehabilitation
7285 W. Ellsworth Road
Ann Arbor, MI 48103
Phone: (734) MAC-9500
Fax: (734) MAC-9555
Email: MACinfo@MichiganAbilitiesCenter.org