Complete this form to authorize a trusted person or people to help manage your 180 Medical account.

Applicant Name *

Primary Contact Email *

Patient Name *

Patient Date of Birth *

I authorize the person or people listed below to act as my representative(s) for my 180 Medical account. I understand this gives them permission to confirm my supply orders, help manage my account, and have access to my confidential personal health information.

First Appointed Person

First Appointed Person (Full Name) *

Relationship to Client --- Spouse Caregiver Other

Relationship to Client (Other)

Complete Mailing Address *

Phone Number *

Additional Appointees

Second Appointed Person (Full Name)

Second Relationship to Client --- Spouse Child Caregiver Other

Second Relationship to Client (Other)

Second Apointed Person Complete Mailing Address

Second Phone Number

Third Appointed Person (Full Name)

Third Relationship to Client --- Spouse Child Caregive Other

Third Relationship to Client (Other)

Third Complete Mailing Address

Third Phone Number

By signing below, I acknowledge this form to remain in full effect until I provide written notification stating otherwise.

Signature *

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