Verbal HIPPA Communication Authorization Consent

Verbal HIPPA Communication Authorization Consent
Patient Legal Name and Phone Number*

First name, Middle initial and Last namePatient Phone Number
Patient's Date of Birth*

MonthDayYear
Date
I, Patient Name*, would like to request that this be kept on file in the event that I am seen or treated by the staff at Riverwood Healthcare Center (Hospital and/or Clinic); and that someone from my family be notified of my condition and discuss my future care on my behalf.
Name and Relationship to Patient Phone Number
Name and Relationship to Patient Phone Number
Name and Relationship to Patient Phone Number
*

Signature of Patient or Legal Guardian Clear
*

Witness Signature Clear
*

MonthDayYear
Date
Should be Empty: