Designate Personal Representative

If a patient choses to designate a personal representative to act on behalf of the patient in making healthcare-related decisions and have unlimited access to the patient's information, please download and complete this form.

If the patient is a minor, a parent or legal guardian must sign.

If the patient is unable to sign for any other reason, a legal representative must sign the designation and submit documentation to verify the authority to sign.

Questions? Call Us at
(800) 708-3230

Email Us!