If you wish to provide consent to a parent, guardian, or other individual, please print and complete the Permission to Discuss Medical Billing and Charges form from the
Billing for Medical Services page and upload below.
Tips to ensure your file can be accurately received and processed:
- Completion of the form in its entirety is required
- Only hand-written signatures will be accepted.
- Use a computer when completing and submitting files.
- Download the file onto a computer and then complete the document on the computer.
- Do not complete the file in a web browser.
- Do not use a mobile device.
- Compatible file formats are .pdf,.doc,.docx,.jpg,.jpeg,.tif,.png.
- There is a limit of 10 files per upload.
- The maximum size of a file is 4MB.