Verbal Communication Authorization Form

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Verbal Communication Authorization Form

Please review and complete information below, sign and submit.

Patient Name*

Patient Date of Birth*

Month

Day

Year

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.

Name 1

Phone

Relationship to Patient

Type of Information

All

Scheduling

Medical

Billing

Name 2

Phone

Relationship to Patient

Type of Information

All

Scheduling

Medical

Billing

Name 3

Phone

Relationship to Patient

Type of Information

All

Scheduling

Medical

Billing

Check here if NO ONE is allowed to call about any of your information.

Specific instructions or limitations

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

Signature of Patient or Guardian*

Relationship to Patient

Today's Date*