Patient Personal Representative Request Form printable pdf download

Patient Personal Representative Request Form

LIFECARE MEDICAL ASSOCIATES, PC

LIFECARE DIAGNOSTICS, INC.

1991 BALSLEY ROAD

SENECA FALLS, NY 13148

Telephone No. (315) 539-0237 Fax No. (315) 539-0940

PATIENT’S PERSONAL REPRESENTATIVE REQUEST FORM

DATE: _____________________

DOB: ____________________

PATIENT’S PHONE NO: ____________

PERSONAL REP’S PHONE NO: _____________

I, ___________________________, hereby authorize _________________________

PATIENT’S NAME

NAME OF PERSONAL REP

to receive and/or obtain information verbally regarding my medical care as

indicated below. If copies are needed, a General Authorization to Disclose Protected

Health Information Form will need to be completed prior to release.

________ALL MEDICAL INFORMATION.

________ALL BILLING INFORMATION.

EXCEPTION(S) AS LISTED BELOW:

_______________________________________________________________________

I understand this document shall remain in effect until such time as revoked by me

in writing. I also understand that a copy of this form is valid as original.

__________________________________

______________________

PATIENT’S SIGNATURE

DATE

__________________________________

______________________

WITNESS

DATE

WHEN COMPLETING THIS DOCUMENT, A WITNESS, WHO IS NOT LISTED AS THE

PERSONAL REPRESENTATIVE, IS REQUIRED TO SIGN AND DATE THE FORM.

FOR OFFICE USE ONLY:

ALERT SHEET CREATED: _____ DATE: ________ INITIALS OF STAFF MEMBER: ________

: _____

IF RECEIVED BY MAIL/FAX: SIGNATURE MATCHED

BY WHOM: ____________

Revised: 2/12

Patient Personal Representative Request Form