Caller Authorization | HIPAA Form
Completed form may be sent via Fax: 336.740.9773 or via e-mail: einfo@emsbilling.com
PO Box 863 Lewisville, NC 27023
0863 |Customer Service: 800.814.5339
PATIENT’S INFORMATION
AUTHORIZATION
I hereby authorize use or disclosure of protected health information about me as described. The
following person/class of person/facility is authorized to use or disclose information and receive
information about me over the phone and make any updates to my contact information:
DISCLOSURE
I understand that the information used or disclosed may be subject to re-disclosure by the person or
class of persons or facility receiving it and would then no longer be protected by federal privacy
regulations. I may revoke this authorization by notifying EMS Management and Consultants in writing of
my desire to revoke it. However, I understand that any action taken in reliance on this authorization
cannot be reversed, and my revocation will not affect those actions.
THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING
/ /
/ /
Patient’s Signature
Patient’s DOB or Social Security Number
Date Signed
/ /
Guardian or Personal Representative of
Patient’s Estate Signature
Relationship to Patient Date Signed
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signature
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signature
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