Memphis Surgery Center

 

Authorization to discuss financial information

 

 

I _____________________________  hereby give permission for the Memphis Surgery Center to discuss the details of my financial account with the following person(s):

 

_____________________________________________________________________

 

I further give the Memphis Surgery Center complete authorization to discuss my financial account with the above mentioned person(s) as long as they are able to provide my date of birth and date of service.  I understand that if this is not met, the Memphis Surgery Center will not discuss my account.

 

 

 

 

______________________________________________   Date: _____/_____/_____

Patient Signature

 

______________________________________________  Date:  ____/_____/_____

Witness