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180 Medical Appointment of Care Coordinator

To be completed by the party seeking representation (i.e. the beneficiary):

  • Client Name / Account Holder

  • MM slash DD slash YYYY
  • , appoint the following individual(s) to act as my representative(s) in connection with the above-referenced account with 180 Medical, Inc. I authorize them to act on my behalf in the confirmation of my supply order, maintenance of my account, and grant them permission to have access to all my confidential personal health information.

  • By signing below, I acknowledge this form to remain in full effect until I provide written notification stating otherwise.
  • DD slash MM slash YYYY
  • This field is for validation purposes and should be left unchanged.