Consent To Change Personal Health Information Preference (Page 3 of 3) in pdf

Consent To Change Personal Health Information Preference Page 3

beneficiary. Please attach the appropriate documentation to demonstrate

your legal authority to execute this document on behalf of the beneficiary (for

example, Durable Medical Power of Attorney). This box should only be

checked if someone other than the person with Medicare signed above

Print the Personal Representative’s Address (Street Address, City, State, and ZIP):

__________________________________________________________________

Telephone Number of Personal

Representative:

____________________________

Personal Representative's Relationship to the Beneficiary:

________________________

D. How to Submit Your Preference

Fill out, sign and return this form to Michael Mignoli, MD in person, or via mail to

the following address:

Michael Douglas Mignoli, MD

9218 Kimmer Drive

Suite #106

Lone Tree, CO 80124

Call 1-800-MEDICARE at 1-800-633-4227 and say that you want to allow Medicare

to share your personal health information about care you receive from other doctors or

health care providers with Michael Mignoli, MD, or that you want to talk about the

Comprehensive Primary Care Initiative.

Questions

If you have any questions, please call Medicare at 1-800-MEDICARE (1-800-633-4227).

TTY users should call 1-877-486-2048.

Consent To Change Personal Health Information Preference Page 3