Additional Member Forms | Allwell from Silver Summit Health

Additional Forms

 

Use this form when you want to allow us to share your health information with a person or group:

Use this form when you want us to cancel or revoke your previous permission to share health information with a person or group:

 

Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.

If you have questions please, contact Member Services.