• Designated Individuals Authorization Form

    For the practices of Darrell Belcher, Philip Branson, Robert Kropac, & Frederick Morgan

    I hereby authorize one or all of the designated parties below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the indentity of designated parties must be verified before the release of any information.

    Authorized Designees:

  • Date Format: MM slash DD slash YYYY