Ab-2 - Treatment Plan - Accident Claims Benefit Package Page 3
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3Part 7 – Choice in Following Diagnostic and Treatment Protocols
Please state your preference of treatment within or not within the Diagnostic and Treatment Protocols:
I choose to be treated within the Diagnostic and Treatment Protocols as indicated on Form AB-1
I choose not to be treated within the Diagnostic and Treatment Protocols
I am the claimant
I am the authorized representative of the claimant
I certify that the information provided is true and correct to the best of my knowledge. I confirm that I have consented to the collection,
use and disclosure of my personal information for my treatment and care and determination of my eligibility for accident and/or disability
income benefits as outline on Form AB-1.
Name (Please Print)
__________________________________________________________
Signature _
Date
___________________________________________________________________
___________________________________
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AB-2 (2006/01)
Page 3 of 3
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Parent category: Medical