University of North Carolina Health Care System - UNC Health Care
University of North Carolina Health Care System - UNC Health Care
University of North Carolina Health Care System - UNC Health Care
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He leído y entendido la información en este formulario de autorización/I have read and understand the information in this<br />
Authorization form.<br />
Firma del paciente/Signature <strong>of</strong> Patient:<br />
Nombre en letra de imprenta/Printed Name:<br />
Firma del representante autorizado/Signature <strong>of</strong><br />
Authorized Representative:<br />
Nombre en letra de imprenta/Printed Name:<br />
O/OR<br />
Fecha y hora /Date & Time:<br />
Fecha y hora /Date & Time:<br />
Favor de explicar la autoridad del representante para actuar en nombre del paciente/Please explain Representative’s authority to<br />
act on the behalf <strong>of</strong> the Patient:<br />
OFFICE USE ONLY<br />
PROCESSED DATE: _____________________<br />
STAMPS / ADDITIONAL NOTES:<br />
PROCESSED BY: _______________________<br />
ADDITIONAL NOTES:<br />
Translated by <strong>UNC</strong> <strong>Health</strong> <strong>Care</strong> Interpreter Services- 05/29/13<br />
HD 555 Rev 05/07 , 08/08, 10/10, 04/13<br />
Chart Location: Authorizations
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