* Any items marked with a red asterisk must be filled out, but any other items may be skipped.
You may Enter or Skip entering the e-mail address below:
** If you enter your e-mail address, be sure to type your e-mail address twice below, just to confirm that we have the right e-mail address.
If you would like to pay any past or upcoming copays, but don't know the amount, please call 205-329-7815 from 8am-noon or from 1pm-4pm to find out what you owe.
I hereby authorize Dr. Azrin, Dr. Millsaps, or Leslie Kahn to obtain and to release my information to the following people, doctors, or facilities: