Form 2001 - Notification Of Appointment Of Personal Representative printable pdf download

FOR OFFICIAL USE ONLY - Confidential

Form 2001 – Notification of Appointment of Personal Representative

Form: Notification of Appointment of Personal Representative

I, _________________________ (person designated as personal representative) have been designated the personal representative

of _________________________________ (subject). I declare that I have the authority granted by the State or the courts to act

on the behalf of the subject .

Authority to act as personal representative demonstrated by (Attach copy):

Court Order or Power of Attorney

Will or other Document Designating Executor or Administrator with Authority to Act on Behalf of a Deceased

Individual

Proof as Parent or Guardian of Unemancipated Minor

Designation of loco parentis (in place of the parents) for an unemancipated minor

* Such person may not be a personal representative of an unemancipated minor, and the minor has the authority to act as an individual, with respect to

protected health information pertaining to a health care service if:

(A) The minor consents to such health care service; no other consent to such health care service is required by law, regardless of whether the consent of

another person has also been obtained; and the minor has not requested that such person be treated as the personal representative;

(B) The minor may lawfully obtain such health care service without the consent of a parent, guardian, or other person acting in loco parentis, and the minor,

a court, or another person authorized by law consents to such health care service; or

(C) A parent, guardian, or other person acting in loco parentis assents to an agreement of confidentiality between a covered health care provider and the

minor with respect to such health care service.

(ii) Notwithstanding the provisions of paragraph (g)(3)(i) of this section:

(A) If, and to the extent, permitted or required by an applicable provision of State or other law, including applicable case laws, a covered entity may disclose,

or provide access in accordance with § 164.524 to, protected health information about an unemancipated minor to a parent, guardian, or other person

acting in loco parentis;

(B) If, and to the extent, prohibited by an applicable provision of State or other law, including applicable case law, a covered entity may not disclose, or

provide access in accordanct with § 164.524 to, protected health information about an unemancipated minor to a parent, guardian, or other person acting

in loco parentis; and

(C) Where the parent, guardian, or other person acting in loco parentis, is not the personal representative under paragraph (g)(3)(i)(A), (B), or (C) of this

section and where there is no applicable access provision under State or other law, including case law, a covered entity may provide or deny access

under

§ 164.524 to a parent, guardian, or other person acting in loco parentis, if such action is consistent with State or other applicable law, provided that such

decision must be made by a licensed health care professional, in the exercise of professional judgment.

Information on Personal Representative

Name: ______________________________________________________________________________________________

Address: ____________________________________________________________________________________________

___________________________________________________________________________________________________

Signature: ___________________________________________________________________________________________

NOTE: This request will remain in effect until you notify us in writing of a change.

Information on Member

Name: _____________________________________________________________________________________________

Address: ____________________________________________________________________________________________

___________________________________________________________________________________________________

Individual’s Date of Birth: __________________________________ Individual’s SS#: _____________________________

Signature: ___________________________________________________________________________________________

The identity of the requestor has been validated either with a picture ID, such as a driver’s license or passport, or comparison

of signatures documented in the PHI records by _____________________________ [Name of Entity staff validating identity]

PP Personal Representatives

Form 2001 - Notification Of Appointment Of Personal Representative

Related Articles

Related forms

Related Categories