Form Phc-Mr091 - Authorization For The Release Of Health Records Page 2
Download a blank fillable Form Phc-Mr091 - Authorization For The Release Of Health Records in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Phc-Mr091 - Authorization For The Release Of Health Records with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6Complete this side only if Part 5 on front of form is completed
Authorization on behalf of an incapable adult
Any of the following, acting within their duties or powers, may provide authorization on behalf of an adult:
□ Committee appointed by court order (where records are required to carry out committee’s duties)
□ Person acting under a Power of Attorney (where records are required for financial or legal matters)
□ Litigation Guardian (where records are required for litigation)
□ Representative under a Representation Agreement (where records are required to carry out representative’s duties)
If none of the above have been appointed, please explain relationship to patient:
Authorization on behalf of an incapable minor
Complete this section if patient is a minor:
under 12; or
under 19 and not actively involved in decisions about health care.
Note: Patient authorization is required if patient is involved in decisions about care or has provided consent for care.
Guardian:
□ by court order
□ under a legal agreement
□ parent who has lived with or regularly cared for child and there is no order or agreement removing my guardianship
Authorization on behalf of a deceased patient
Deceased Adult
□ Committee appointed by court order
□ If there is no Committee, Personal Representative (Executor or Administrator of Estate)
If there is no Committee or Personal Representative:
Nearest Relative: first person referred to in the following list who is willing and able to act on behalf of deceased:
□ Spouse
□ Adult child
□ Parent
□ Adult brother or sister
□ Other adult relation other than by marriage:
□ An adult immediately related by marriage:
Deceased Minor (under 19)
□ Personal Representative (Executor or Administrator of Estate)
□ If there is no Personal Representative, Guardian (appointed by court, under an agreement, or a parent who
has lived with or regularly cared for child)
If there is no Personal Representative or Guardian:
Nearest Relative: first person who is willing and able to act on behalf of deceased:
□ Spouse
□ Parent
□ Adult brother or sister
□ Other adult relation other than by marriage:
□ An adult immediately related by marriage:
Form No. PHC-MR091 (Aug 26-15)
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Hud-9886 - Authorization For The Release Of Information / Privacy Act Notice - U.s. Department Of Housing And Urban Development
Legal
Form 104 - Ohio Northern University Hipaa Compliant Authorization For The Release Of Protected Health Information
Medical
Related Categories
Parent category: Business