| Patient |
Patient’s photo ID |
May request only if patient has no difficulty in communication |
| Immediate Family Member (Patient’s spouse, parents, grandparents, children, grandchildren, in-laws) |
ACopy of patient’s ID |
Applicant’s photo ID |
| Applicant’s photo ID |
| Proof of Family (i.e. birth certificate) |
Proof of Family (i.e. birth certificate) |
| Patient consent form (signed)
|
| Power of Attorney (Siblings, Insurance Company, etc.) |
Copy of patient’s ID |
Parents/Power of Attorney’s photo ID |
| Proof of Family (i.e. birth certificate) |
| Applicant’s photo ID |
Applicant’s photo ID |
Patient consent form (signed by patient)
|
Parents/Power of Attorney’s consent form (signed) |
Power of Attorney (signed by patient)
|
Parents/Power of Attorney’s consent form (signed) |