Appointment and Billing Communication Directive

Joan M. Franklin Ph.D.

Joan M. Franklin Ph. D. 2249 Ridge Rd Rockwall, TX 75087 469-402-3604 * Fax 469-402-3606 www.joanmfranklinphd.com

DIRECTIVE FOR HANDLING OF APPOINTMENTS AND BILLING INFORMATION
This form authorizes us to contact or leave messages for you and all listed for appointment and billing information.
For adult patients, if someone other than yourself will be paying for your visits you must list that individual below
to authorize us to collect appropriate payment.

"*" indicates required fields

Name of Patient*

Name of Contact*

I, undersigned Patient, Parent, Guardian, or Personal Representative authorize the office of Joan M. Franklin, Ph.D. to contact me in the following ways:

Number/Email*

Home

May leave a message(Y/N)*

Home

Preferred*

Home

Number/Email*

Work

May leave a message(Y/N)*

Work

Preferred*

Work

Number/Email*

Cell

May leave a message(Y/N)*

Cell

Preferred*

Cell

Number/Email*

Fax

May leave a message(Y/N)*

Fax

Preferred*

Fax

Number/Email*

May leave a message(Y/N)*

Preferred*

*There is always a risk in sharing information electronically. Please know that information shared via email, fax, or text could be saved to the internet and has the potential to be altered.

Other persons we may contact: (If anyone other than the patient or legal guardian is providing payment, please list their contact information below to discuss and handle any potential payment issues.)

Name*

Relationship*

Number/Email*

Message(Y/N)*

Name*

Relationship*

Number/Email*

Message(Y/N)*

I further authorize the office of Joan M. Franklin Ph.D. to contact the Emergency Contact(s) listed on the registration page.

Signature /Patient:

Date

OR Parent/Guardian/Legal Responsible Person

If the patient is either under age or has a guardian appointed by court, this request must be signed by the patient’s legal guardian. If the request is signed by a personal representative of the patient, a legal document stating such representative’s authority to act for the patient must be provided.