PATIENTS RELEASE
Joined: 15 May 2003
Posts: 1
Posted: Thu May 15, 2003 12:13 pm Post subject: ADVOCACY AUTHORIZATION
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>website:
http://www.dialysisethics.org/<
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>PATIENT RELEASE AND AUTHORIZATION REQUEST/FOR PATIENT ADVOCATE, per FEDERAL LAW.<
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>DATE_______________<
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>PATIENTS NAME___________________________<
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>PATIENTS CLINIC NAME AND ADDRESS___________<
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>_____________________________________________<
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>CLINICS PHONE NUMBER________________<
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>PHYSICIANS NAME___________________<
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>THIS IS MY OFFICIAL REQUEST UNDER FEDERAL LAW TO ALLOW THE ABOVE ORGANIZATION TO ADVOCATE ON MY BEHALF. DIALYSIS ETHICS HAS MY PERMISSION TO BRING IN ANYONE TO HELP ME/ THAT WOULD HELP WITH THE RESOLUTION OF MY COMPLAINT AND AM EXERCISING MY PATIENT RIGHT TO DO SO.<
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>I want Dialysis Ethics.org to advocate for me for the following issue or issues<
>_Personal<
>_Other<
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>* I also understand that I have the right to revoke this authorization at any time in writing.This authorization shall expire in 90 days. I also understand that I need to have 3 copies made. One for myself.Original signatures to Dialysis Ethics and to the clinic. Once the fax is received we can start. <
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>_________________ _____________________<
> signature of patient signature of witness or notary<
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