eHIPAA

For questions and inquiries,
please contact Verona Pathway Plus:
Phone: 833-372-8492
Fax: 833-392-8999
Hours of Operations: 8AM - 8PM EST
Monday through Friday,
not including holidays.

Your session has been inactive for a while now and will expire in two minutes, do you want to continue this session?

About This Form

PATIENT AUTHORIZATION AND CONSENT ARE REQUIRED FOR ACCESS TO VERONA PATHWAY PLUS SUPPORT PROGRAMS
• COPAY ASSISTANCE
• INSURANCE EDUCATION
• COVERAGE DELAY PROGRAM
• PATIENT ASSISTANCE PROGRAM
• ADDITIONAL RESOURCES

Your privacy is important to us. In order for us to provide support services, we will need your authorization and consent to use your health information called Protected Health Information (PHI) and to share them with your health plan and other companies that are necessary to support your treatment.

Patient Information

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

Address 1 *

Address 2

City *

Zip Code *

I am signing as parent or guardian (legal representative) of the patient.

Contact Information

Email Address *

Patient Cell #

555-555-5555

For questions and inquiries,
please contact Verona Pathway Plus:
Phone: 833-372-8492
Fax: 833-392-8999
Hours of Operations: 8AM - 8PM EST
Monday through Friday,
not including holidays.

About This Form

Patient Information

Legal Representative Information

Contact Information