Healthcare Authority Agreement

HEALTHCARE AUTHORITY AGREEMENT

Parties and Effective Dates

Patient Name:

Date of Birth:    Gender:

Authorized Representative

Authorized Representative Name:

Agreement Effective Date:    Authorization Expiration Date:

Scope of Authority (check all that apply)

Access, inspect, and receive copies of medical and billing records, including electronic records.

Provide informed consent for routine and non-experimental medical treatment on behalf of the patient.

Discuss, manage, and sign insurance claims, billing inquiries, and payment arrangements related to health care services.

Obtain prescriptions and medication refills and receive medication-related information.

Schedule, reschedule, and cancel appointments; receive appointment and treatment instructions.

Access patient health portals and electronic communications on behalf of the patient.

Other (specify):

Limitations and Conditions

The authority granted herein is limited to the items expressly checked above. This Authorization does not authorize the Authorized Representative to execute a will or make final decisions regarding life-sustaining treatment, withdrawal of life-sustaining treatment, or other advance directive decisions unless an explicit statement to that effect is initialed below and the representative is appointed under a separate durable power of attorney for health care.

Initial to permit authority for end-of-life decisions:

The Authorized Representative shall act in accordance with applicable law and the known wishes of the patient. The Representative shall not use this Agreement to obtain financial information or control accounts except to the extent necessary to process health care claims or payments.

HIPAA and Privacy Authorization

I authorize all my health care providers, health plans, health care clearinghouses, and their agents to disclose and release protected health information to the Authorized Representative to the extent necessary to carry out the authority granted above. This authorization includes, but is not limited to, diagnostic reports, treatment records, billing records, and electronic communications.

I understand that information disclosed pursuant to this Authorization may be re-disclosed by the Authorized Representative and no longer be protected by federal privacy law. I have the right to revoke this Authorization in writing at any time except to the extent action has already been taken based on this Authorization.

This Authorization is valid until the Authorization Expiration Date listed above or until revoked in writing by the patient. Revocation must be delivered to the patient's health care provider and to the Authorized Representative.

Indemnification and Reliance

The patient agrees to indemnify and hold harmless health care providers and their employees from liability for actions taken in good faith reliance upon this Agreement. Health care providers may require verification of the Authorized Representative's identity before disclosing information or accepting instructions.

Insurance and Medical Information

Emergency Contact

Acknowledgment and Certification

By signing below, I certify that I am the patient named above or the patient's legal guardian or authorized representative. I understand the nature and consequences of this Healthcare Authority Agreement, that I may revoke it at any time by providing written notice to my health care providers, and that health care providers may rely on this Agreement until they receive timely written revocation. I acknowledge that I have read and understand this Authorization and that my consent is given voluntarily.

Sign Now