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Auth to Discuss Info

  • Authorization to Discuss Your Information with Family or Caregiver

    To comply with the new HIPAA Federal Privacy Regulations, we must receive your written approval to discuss information about you with anyone else including your family, children, and/or caregivers. With your authorization, we will be able to discuss your case, answer questions, leave detailed messages, or contact for other reasons the person(s) listed below. This authorization is optional and you can withdraw it at any time.

  • MM slash DD slash YYYY
  • NameRelationshipPhone Number 
  • How to best contact you

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    MM slash DD slash YYYY