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AUTHORIZATION TO DISCLOSE INFORMATION
TO A PERSONAL REPRESENTATIVE
 

You may request staff in the above named office to disclose limited information regarding your healthcare to your personal representative. Please be aware we will only provide information to the person(s) named on this form. This authorization will remain vaild until revoked in writing, unless you specify a calendar date.
Patient Name:   DOB: 
Date on which this authorization becomes invalid:
(If blank, this authorization will remain in effect until revoked in writing.)
I request the following person(s) to receive information about my health care.
Name:   Relationship: 
Name:   Relationship: 
Name:   Relationship: 
Name:   Relationship: 
Type of information we disclose:
Appointments, test results, diagnosis, medications, referrals and billing.
Okay to leave information on answering machine?
Signature:   Date: