Authorization to Speak with Family Member Consent Form
Please complete this form to authorize our organization to communicate with your designated family member. All fields are required for your authorization to be processed.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Authorized Family Member
*
First Name
Last Name
Relationship to You
*
Please Select
Spouse
Parent
Child
Sibling
Grandparent
Other
Authorized Family Member's Email Address
*
example@example.com
Authorized Family Member's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Purpose of Authorization
*
Authorization Duration
*
Please Select
Ongoing until revoked
One-time authorization
Valid for 6 months
Valid for 1 year
Submit Authorization
Should be Empty: