Patient Advocate Authorization Form
Please fill out this form to authorize a patient advocate to act on your behalf.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Advocate Full Name
*
First Name
Last Name
Advocate Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Advocate Email Address
*
example@example.com
Relationship to Patient
*
Please specify the scope of authorization granted to the advocate.
*
Patient Signature
*
Date of Authorization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: