Patient Consent Form

Patient's Legal Name:
Date of Birth:

I give the following individual(s) permission to speak on my behalf. They are allowed access to my billing information and/or medical records (for example: to schedule/cancel appointments, billing questions/payments, request for prescription refill, discuss biopsy results, etc.). I understand that I can add or remove anyone from this list at anytime by filling out another consent form.

Name:
Relationship:
Type of Access Allowed:
For How Long?

Name:
Relationship:
Type of Access Allowed:
For How Long?

Name:
Relationship:
Type of Access Allowed:
For How Long?

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Patient Signature:
Date: