Personal Representative Form - Bluegrass Internal Medicine printable pdf download

Personal Representative Form - Bluegrass Internal Medicine

BLUEGRASS INTERNAL MEDICINE

PATIENT NAME:____________________________DATE OF BIRTH:________________

PERSONAL REPRESENTATIVE:

I authorize Bluegrass Internal Medicine to give to my personal representative(s), as named

below, protected health information on my behalf.

NAME

RELATIONSHIP

________________________________________________________________________

PLEASE CHECK ALL THAT APPLY:

I wish to be contacted about my protected health information in the following manner:

o Home Telephone #_____________________

o Cell Phone #__________________________

o Written Communication (Mail)

o Work Telephone #______________________

o Other:________________________________

I acknowledge that I have received a copy of the Notice of Privacy Practices of Bluegrass

Internal Medicine.

________________________________________________________________________

CONSENT: I hereby consent to Bluegrass Internal Medicine using or disclosing my

protected health information for the purpose of providing treatment to me, obtaining

payment for health care services rendered to me or to carry out Bluegrass Internal

Medicine health care operations. I authorize examination and any other medical services

deemed necessary by the physician. I authorize the release of any protected health

information to another physician or my insurance company, unless specifically requested in

writing by me. This protected health information includes any personal or confidential

information of a sensitive nature such as psychological or psychiatric records, substance

abuse, drug or alcohol treatment or information pertaining to communicable diseases

(including HIV status, hepatitis, or venereal diseases). I understand and agree to these

conditions as a patient of Bluegrass Internal Medicine.

PATIENT SIGNATURE:________________________________________________

Personal Representative Form - Bluegrass Internal Medicine