Please list any family members or other individuals who may be involved in coordinating your care, or payment for your care. Please indicate what types of information may be shared with each individual.
We will rely on the information on this form when communicating regarding your care unless you request changes. Please notify our office if you wish to alter the above designations. Signed original will be placed in your medial record.
To revoke this authorization, please send a written request to:
305 W Park St.
Livingston, MT 59047
Received. Thanks for submitting.