To act as the authorized representative in the above-captioned matter. If you are not next of kin, please complete the "authorization" section below.By signing this form, you allow us to share your protected health information (PHI) with the persons and organizations you put on this form. This Authorization Letter sample is available for use on UpCounsel. I authorize the company stated below to submit my passport application to a passport agency and pick up the passport from a U.S. passport agency on my behalf. When requesting form completion via MYCHOP, the completed form can be sent to your account to enable you to print, save or send it. A letter is sent to you informing you of your assigned CAF number. Please note that these forms are meant to be downloaded and filled in, and may not work properly in your browser window. Request form instructions. Providers. When completing a prior authorization form, be sure to supply all requested information.

Sample Letter For Authorization In Philadelphia

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