Contact Authorization

Name*

First NameMiddle NameLast Name

Date

In the event that Miami Valley Recovery needs to contact you via telephone or mail, please answer the following questions “yes” or “no” as an authorization.

1. May we contact you at home?*

YESNO

2. May we leave a message on your answering machine?*

YESNO

3. May we contact you on your cell phone?*

YESNO

4. May we leave a message on your voicemail?*

YESNO

5. May we leave a message with a third party (anyone who may answer the phone) and/or your emergency contact?*

YESNO

6. May we contact you at your place of employment?*

YESNO

7. May we send correspondence to you at the address we have on file for you?*

YESNO

In order for Miami Valley Recovery to contact you, we must have a working phone number on file to reach you. It is important that we have a phone number, cell phone number and a contact person’s phone number that can relay a message to you. It is your responsibility to give these numbers to our office and to inform us as soon as these numbers change.

Once we speak with you or your contact, we request that you follow through with your commitment. If we need to leave a message on your voicemail, it is your responsibility to contact our office.

Random drug screens and medicine counts are part of your agreement when receiving treatment at Miami Valley Recovery, so we need to be able to let you know when those are needed. Also, there are times we will call with appointment reminders and check in calls if we have concerns. All of this helps us provide the best possible treatment for you.

Signature*

Cell Phone Number*

Area CodePhone Number

Home Phone Number

Area CodePhone Number

Emergency Contact Name*

Emergency Contact Phone*