Dr. Kropac Designated Individuals Authorization

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:
Name*
First Last
Email*
Relationship:*
Name
First Last
Relationship:
Name
First Last
Relationship:
Name
First Last
Relationship:
Patient Name:*
First Last
Signature:*
Date*
MM slash DD slash YYYY
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Address:
311 Courthouse Rd
Princeton,WV2470

Phone:
(304) 425-9563

NOTICE OF NONDISCRIMINATION:
Orthopedic Center of the Virginias complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Orthopedic Center of the Virginias does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. ATTENTION: If you do not speak English, language assistance services, free of charge are available to you via Fluent Language Services 1-888-306-7726. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. 1-888-306-7726. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。1-888-306-7726.

Dr. Kropac Designated Individuals Authorization

Designated Individuals Authorization Form

Your Doctors

Documents

Contact Us