Phone Authorization Form Patient NameDo we have your permission to call you atHome Yes No PhoneWork Yes No PhoneCell Yes No PhoneDo we have your permission to discuss you medical history and account withSpouse Yes No NameDependent Yes No NameOther Yes No NameEmergency contactRelationshipTelephoneOther TelephonePatient or Guardian's SignatureDate MM slash DD slash YYYY If a personal representative signs this authorization on behalf of the individual. Complete the following:Personal Representative's NameRelationship to Individual
