Designation of Personal Representative

Designation of Personal Representative

(For Use/Disclosure of Health Information Only)
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.
Representative's Name
Relationship to you
Representative's Phone Number
This person shall be given all of the privileges that would belong to me regarding my health information.

I understand that I may revoke this designation at any time by signing a revocation and delivering it to The Family Doctors. I further understand that any revocation will not apply to the extent that persons authorized to use of disclose my health information have have already acted in reliance on my previous designation.
Name: (typing your name below will serve as your electronic signature)

First Name Last Name
Date

Month Day Year
Date
Should be Empty: