Healthcare Legacy Agreement

Healthcare Legacy Agreement

INTRODUCTION AND RECITALS

This Healthcare Legacy Agreement documents the decisions and authorizations of the person identified below regarding the retention, disclosure and disposition of medical records and related health information for legacy purposes, including posthumous access, archival preservation and authorized sharing with designated legacy contacts. Patient Name: Date of Birth:

PATIENT CONTACT INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY SUMMARY

DESIGNATION OF LEGACY CUSTODIAN(S)

Primary Legacy Custodian Name: Relationship:

SCOPE OF AUTHORIZATION

I authorize my healthcare providers and record custodians to disclose the following categories of health information to the named legacy custodian(s) for the purposes stated herein. Select all categories authorized for release:

Full medical record (including notes, hospital records, imaging)

Mental health and psychiatric records

Substance use treatment records

Genetic testing results and counseling records

Radiology, imaging and diagnostic reports

Billing and insurance claim records

Other:

RETENTION, TRANSFER AND DISPOSITION

I direct that medical records and related materials covered by this Agreement be retained and/or transferred as follows. If multiple custodians are identified, transfer will follow this priority: primary custodian, then alternate custodian. Retention preference:

Preserve permanently for family legacy and archival purposes

Retain for a limited period (specify expiration date)

Special instructions regarding sensitive content, recordings, or material to be withheld:

AUTHORIZATION, CONSENT, AND LIMITATIONS

By signing below I authorize release of the categories of information selected above to the named legacy custodian(s) for the stated purposes. I understand and agree that:

1. The custodian(s) may receive, store, reproduce and share the authorized information consistent with this Agreement. The custodian(s) may further permit dissemination to other persons expressly authorized in writing by me or by my estate. The custodian(s) are not agents of my healthcare providers unless expressly appointed in separate documentation.

2. I may revoke this Agreement at any time by submitting a written revocation to my healthcare provider and to the custodian(s). Revocation is not effective to the extent that action has already been taken in reliance on this authorization, including disclosures already made.

3. This Agreement does not authorize the custodian(s) to make medical decisions on my behalf. It is limited to retention, disclosure and legacy use of health information as described here and does not alter any advance directive, power of attorney, or other legal instrument unless expressly stated.

HIPAA PRIVACY ACKNOWLEDGMENT

I acknowledge that protected health information disclosed in accordance with this Agreement may be subject to redisclosure by the recipient and may no longer be protected by federal privacy rules. I understand that my healthcare providers may require reasonable proof of identity and may charge a fee for copying and transferring records consistent with applicable law.

I acknowledge and accept the terms of this HIPAA privacy acknowledgment and the scope of authorization set forth above.

AUTHORIZATION DURATION AND EFFECTIVE DATE

This Authorization is effective as of: and will expire on: unless earlier revoked in writing.

REPRESENTATIONS, WARRANTIES AND GOVERNING LAW

I represent that I have legal authority to execute this Agreement with respect to my own health information. If signing as a legal guardian, conservator or person authorized under applicable law, I certify that I have the authority to act for the patient and will provide documentation upon request. This Agreement shall be governed by the laws of the state applicable to the location where the patient primarily receives care, without regard to choice of law principles. If any provision of this Agreement is found invalid, the remainder shall remain in full force and effect.

ADDITIONAL AUTHORIZATIONS (OPTIONAL)

I authorize release and retention of audio and/or visual recordings relating to my care for legacy purposes.

I authorize use of de-identified information for research or educational purposes consistent with applicable law.

CERTIFICATION

I certify under penalty of perjury that the information provided in this Healthcare Legacy Agreement is true and correct to the best of my knowledge and that this authorization is voluntary. I understand the duties, rights and limitations described herein.

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