Appointment of Authorized Representative
This form is used by an individual to appoint HealthConsent as their authorized representative to act on their behalf in connection with uses and disclosures of the individual’s protected health information and records, as well as the individual’s rights under the Privacy Rule at 45 CFR 164.502(g).
1. Individual Appointing Authorized Representative
| Name: | |
|---|---|
| Address: | Email: |
| Date of Birth: | Phone: |
I am signing this form to:
_ Appoint a representative
_ Revoke an existing appointment of representative
I am the:
_ Individual
_ Parent of a Minor
_ Guardian
_ Conservator
_ Administrator of Estate
_ Executor of will
_ Other
2. Authorized Representative Duties
- To request an accounting of disclosures in accordance with 45 CFR 164.528
- To revoke any previous authorizations to use and disclose personal health information and records
- To revoke any previous authorization for the disclosure of protected health information for marketing purposes
- To request to restrict any further disclosures of the individual’s health information and healthcare records
- To request deletion of personal health information
3. Effective Date
4. Identity Verification
5. Authorized Representative
| Name: | ||
|---|---|---|
| Address: | ||
| Email: | Phone: | Fax: |
6. Individual Authorization
By signing below, I hereby appoint HealthConsent as my authorized representative. I agree that:
- The authorized representative may perform duties on my behalf (as indicated in section 2)
- This authorization starts on the date I sign this form
- The authorized representative may cancel this appointment at any time
- I may update or revoke this authorization at any time
- I will not be denied eligibility, treatment, or payment for health care
- I understand that signing this appointment is voluntary
//Signature// //Date//
If parent of a minor, name of minor:
Relationship to minor: