EmailMe Form - PERSONAL REPRESENTATIVE/CONFIDENTIAL COMMUNICATION

In accordance with the Health Information Portability and Accountability Act of 1966 you have the right to request a personal representative to act on your behalf, and that communications concerning your personal health information can be made through confidential channels. This practice will not question your question your request and will make every effort to accomodate all reasonable requests.

Please list all family members or other persons, if any, who we may inform or discuss your general medical condition and diagnosis (including treatment, payment, and health care operations and appointments.)

NAME

DATE OF BIRTH

MM / DD / YYYY

NAME OF PATIENT
OR GUARDIAN

OFFICIAL SIGNATURE

CHECK HERE FOR OFFICIAL SIGNATURE

BY CHECKING THE BOX ABOVE, I CONSIDER THIS FORM LEGALLY SIGNED BY ME OR MY GUARDIAN

NAME OF PERSON
SIGNING CONSENT

ENTER THE DATE
YOU CONSIDER
THIS FORM OFFICIALLY
SIGNED

MM / DD / YYYY

Signing this box impies a complete and total understanding of the above information.

Clear

Use finger to draw a legible signature then hit
the submit button athe the bttom