THE IRIS NETWORK REHABILITATION CENTER
Please complete both the Client Application Form and the VRC/Payor Authorization Form, and return them along with the requested attachments (See attachments section).
Client Application and VRC/Payor Authorization Forms can be submitted online, by email, or via mail.
Online Submission: Click on each link below to fill out and submit forms. Once completed, email or mail the requested attachments (See attachments section).
Click Here for the online Client Application Form
Click Here for the online VRC/Payor Authorization Form
Email or mail submission: Click on each link below to download a Word Document or PDF form. Once completed, email or mail forms.
Client Application Form
Click Here for the Download and Fill Client Application Form in Word
Click Here for the Download and Fill Client Application Form in pdf
VRC/Payor Authorization Form
Click Here for the Download and Fill VRC/Payor Authorization Form in Word
Click Here for the Download and Fill VRC/Payor Authorization Form in pdf
Forms can be emailed to admissions@theiris.org OR mailed to The Iris Network Rehabilitation Center, Attn: Amber, 189 Park Avenue, Portland, ME 04102
We request the following attachments:
- Your most recent eye report, which should be no older than 1 year. To get a copy of your eye report, contact your eye doctor.
- A medical report from your primary care physician; you may download our Request for Medical Information. The report should include a physical, cognitive, and emotional assessment. The report should indicate whether your physician feels you require limitations or restrictions to activity while at The Rehabilitation Center.
- Copies of your most recent vision rehabilitation reports.
- A copy of your health insurance card (front and back).
- A copy of your guardianship decree, if applicable.
If you have any questions, please do not hesitate to contact us at the number below.
Amber, 1-207-774-6273 ext. 3329