ProviderListSignature


Patient:    

Date of Birth:  

Patient's Provider List:

I authorize said healthcare providers listed below, to disclose records obtained in the course of my evaluation and/or treatment to be delivered to the above party preferably by means of an FHIR Interface so that updates can be made with a minimum of human interaction.  If this method is unavailable, Electronic facsimile and/or email is preferred.  In the case where the only option is via paper, please send by U.S.P.S. or delivery service.

CriticalConnection Health Foundation
8400 North MoPac Expressway, Suite 200
Austin TX 78759
Phone: (512) 236 - 1887
Email: PatientForms@criticalconnection.com
Fax: 877-479-4066

 Provider List by Clinic or Facility (add city and state)

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Signature Certificate
Document name: ProviderListSignature
lock iconUnique Document ID: 56f47348c2d2d8ecb40238d445f705078e1c0abc
Timestamp Audit
June 27, 2022 4:42 pm CSTProviderListSignature Uploaded by Christopher Smith - PatientForms@CriticalConnection.com IP 74.194.174.172