180 Medical Appointment of Care Coordinator

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

Client Name / Account Holder
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
I,*

, 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.
First Appointed Person*
Relationship to Client*
Complete Mailing Address*
Phone Number*
Second Appointed Person*
Relationship to Client*
Complete Mailing Address*
Phone Number*
Third Appointed Person*
Relationship to Client*
Complete Mailing Address*
Phone Number*
By signing below, I acknowledge this form to remain in full effect until I provide written notification stating otherwise.
Signature*
Date*
DD slash MM slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Call Toll-Free (877) 688-2729

Thank you for the absolutely wonderful support and service you have provided me as a new customer. I was a bit nervous and apprehensive about my medical condition and how to adopt and embrace the new treatment it required. You were the most thoughtful, articulate and professional in guiding me through the application and answering all my questions. I believe it was the best, most positive customer experience that I have had with a customer support call center. Thanks again.

James P.

180 Medical Appointment of Care Coordinator

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

Client Name / Account Holder