Personal Representative Form

Personal Representative Form
Patient's name*

First NameMiddle (Optional)Last Name
Your privacy is important to us. We will not discuss personal information about your test results, appointments, or billing with anyone else without your permission.
Would you like to appoint a personal representative to act on your behalf?

NO, my test results, appointment information, and insurance/billing/claims may not be discussed with anyone but myselfYES, I would like to appoint a personal representative (i.e. spouse, family member, friend, etc.) to act on my behalf in discussing my imaging results, pathology results, and/or insurance, billing and claims information. Regarding imaging and/or pathology results, I understand that Weinstein Imaging will make every attempt to contact me first.
Name(s) of personal representative(s)
Relationship to you
Phone

Area CodePhone Number
You are giving us permission to speak to this representative ONLY about the items that are selected below:

Imaging study resultsPathology resultsAppointment informationInsurance/billing and/or claims
By submitting the information below, you are electronically signing this form.
Name*
Birth date*

MonthDayYear
Should be Empty: