Summary: As required by the Health Information Portability and Accountability Act of 1996, you have a right to
nominate one or more persons to act on your behalf with respect to the protection of health information that
pertains to you. By completing this form you are informing us of your wish to designate the named person
as your personal representative. You may revoke this designation at any time by signing and dating the
revocation of your copy of this form and returning it to this office.
I request the following person to act as my personal representative with respect to decisions involving the use
and/or disclosure of my protected health information:
What relationship is this person to you?
I understand that I may revoke this designation at any time by signing the revocation section of my copy of
this form and returning it to:
I further understand that any such revocation does not apply if that person or persons authorized to use or
disclose my protected health information have already taken action on my behalf.