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.)
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  • BY CHECKING THE BOX ABOVE, I CONSIDER THIS FORM LEGALLY SIGNED BY ME OR MY GUARDIAN
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  • Use finger to draw a legible signature then hit
    the submit button athe the bttom