Complete this form to request an advocate for your outpatient procedure.
Prefer the Patient ID from Patient Info. Full name is only accepted when it uniquely matches one patient (never a best-guess match). If this is a new patient, use Service Request or Patient Info first so the patient is saved before this form.
If you have not yet completed a provider-specific HIPAA release, you can download the form from our HIPAA Forms page.
Your information is handled in accordance with our HIPAA privacy practices. Submissions create an OutPatient Procedure Advocacy service record for the patient.
