Authorization for Representative

Authorization for Family Member/Personal Representative
I authorize the person(s) (adults age 18 and over) identified below to communicate with Compass Counseling Services, LLC (CCS) in regards to my health care information for specific purposes.
Name *
Phone *
Relationship to Patient *
I authorize this person to (please check all that apply) *

ALL PURPOSES LISTED HERE Create/Cancel Appointments Pick Up Medical Records Pick Up Forms/Letters Discuss Billing Information Participate in Sessions Pick Up Prescriptions in Office
Name
Phone
Relationship to Patient
I authorize this person to (please check all that apply)

ALL PURPOSES LISTED HERE Create/Cancel Appointments Pick Up Medical Records Pick Up Forms/Letters Discuss Billing Information Participate in Sessions Pick Up Prescriptions in Office
Name
Phone
Relationship to Patient
I authorize this person to (please check all that apply)

ALL PURPOSES LISTED HERE Create/Cancel Appointments Pick Up Medical Records Pick Up Forms/Letters Discuss Billing Information Participate in Sessions Pick Up Prescriptions in Office
My signature below represents that I understand this form is valid for one year from date of signature and may be revoked by me (or my legal representative) at any time in writing to CCS. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services or eligibility for benefits. Additionally, I understand that a separate Authorization is needed if I want to give someone full access to my health record.
Client's Name *
Date of Birth *

Month Day Year
Date
Signature of Client *

Clear
Today's Date *

Month Day Year
Date
Print Name of Legal Guardian or Representative
Signature of Legal Guardian or Representative

Clear
Today's Date

Month Day Year
Date
Should be Empty:

Authorization for Family Member/Personal Representative