Designation Form For Release Of Medical Information To A Family Member, Friend, Or Legal Representative


Designation for Release of Medical Information to a Family Member, Friend, or Legal Representative
It is the physicians’ responsibility to ensure that the physician-patient relationship is confidential. The Health
Portability and Accountability Act (HIPPA) allow physicians to use their professional judgment on disclosing
certain personal health information to family, friends, etc. without an authorization. This form is an aid to the
physicians in making a determination on disclosing such information. Parker Primary Care realizes that there are
times when you, the patient, may want another person to be knowledgeable about your medical condition or
medical needs. Your doctor wants you to be able, if you so desire, to name a person to whom you want the
office staff to speak with about your medical condition. To enable that, we would ask that you complete the
form listed below. Please note the following points:
 Only one person can be designated for this role
 The designation is valid until you cancel it in writing
 If you designate no one, Parker Primary Care will not release information to any family member, friend,
or legal representative
Designation Statement
I, ______________________________________, designate the following person to be able to speak to a
physician at Parker Primary Care, or other staff member, should it be necessary, on my behalf. I hereby give
permission to Parker Primary Care through its physicians and staff to release to my designee any information
about my medical condition or medical needs or the status of my account and I release Parker Primary Care its
physicians and staff, from any claim of confidentiality in connections with the release of this information.
Name of Designated Person: _____________________________________________________________
Relationship: _______________________ Phone Number: __________________________ (home/work)
Patient’s Name: _______________________________________________________________________
Patient’s Signature: _____________________________________________________________________
Date: ________________________ Witness: ________________________________________________
I decline to designate another person to speak with my physician or clinical staff.
Patient’s Signature: _____________________________________________________________________
Date: ________________________ Witness: ________________________________________________


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Parent category: Legal