CASE MANAGER PERMISSION FORM

Complete Case Management is one of our most valued services that we can offer you at Elevated Health NYC. We work to get your case approved at no cost to you. Your Case Manager (CM) may need to reach out to others regarding your case at various times throughout the case approval process. Please indicate below who you grant us permission to contact on your behalf:

Please review and initial the following statements where applicable:

I give permission to my Elevated CM to contact my OWCP Claims Examiner to discuss my case.

First Name

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Last Name

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Title

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Phone

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I give permission to my Elevated CM to contact my attorney and/or patient representative to discuss my case.

Name

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Title

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Contact Info (email/phone)

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I give permission to my Elevated CM to contact my Shop Steward/ Union Rep to discuss my case.

Name

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Title

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Contact Info (email/phone)

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Please indicate anyone else that you would like to give us permission to discuss your case with:

I give my permission for my Elevated CM to contact to discuss my case.

Name

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Title

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Contact Info (email/phone)

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I do not give permission to my CM to discuss my case with anyone else other than myself.

Print Name:

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Date:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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