Form Phc-Mr091 - Authorization For The Release Of Health Records Page 4
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63. If no personal representative is named, you may act on the deceased's behalf if you are
the nearest relative of the deceased patient. Those who may act for the deceased
patient have priority in the following order: spouse, child of mature age (12 years of age
or older), parent, sibling, and lastly, any other next of kin who have reached the age of
majority.
4. Health care records are an individual’s personal records, and considered private. Upon
death, a person does not lose their legal right to privacy. We are required by law to
obtain a comprehensive explanation for the reason you are seeking the deceased
patient’s records, including an explanation of how you are acting in the deceased
patient’s best interests.
5. If you are the personal representative or nearest relative of the deceased patient you
must print your full name, sign and date this part.
Step 2: Mail or fax your completed authorization form to each hospital/facility you
are requesting your records from. Refer to the Contact Information document for
addresses and fax numbers.
(Important Note: Please do not send duplicate requests, as this will only delay your
authorization.)
Have questions or need help? Call the Release of Information Office at the
hospital/facility you are requesting records from.
Refer to the Contact Information
document for phone numbers.
Dec 2015
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