The Health Insurance Portability Act of 1996 (HIPAA) grants you the right to designate one or more individuals to act on your behalf regarding the protection of health information that pertains to you. This form indicates your desire to designate the listed individual to be your personal representative for your health information. Your designation can be revoked at any time.
DESIGNATION (leave blank if you do not wish to designate anyone as your personal representative and skip to signature at the bottom of this form)
I, the undersigned, hereby designate the following person to act as my personal representative with respect to decisions regarding the use and/or disclosure of my health information.