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Verbal Communication Authorization Form

Please review and complete information below, sign and submit.

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.

Type of Information
Type of Information
Type of Information

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:

Eyecare Professionals

305 W Park St.

Livingston, MT 59047

Received. Thanks for submitting.

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