Authorization to Speak with Family Member
Provide your consent for our team to communicate with a designated family member about your information.
Your Full Name
*
First Name
Last Name
Your Date of Birth
*
-
Month
-
Day
Year
Date
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email Address
*
example@example.com
Family Member's Full Name
*
First Name
Last Name
Relationship to You
*
Please Select
Parent
Spouse/Partner
Sibling
Child
Other
Family Member's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Family Member's Email Address
example@example.com
Type of Information You Authorize to Be Shared
*
General account information
Appointment details
Billing information
Other
Authorization Expiration Date (if any)
-
Month
-
Day
Year
Date
Additional Instructions or Restrictions (optional)
Signature of Person Giving Authorization
*
Date of Signature
*
-
Month
-
Day
Year
Date
Submit Authorization
Submit Authorization
Should be Empty: