Healthcare Patient and Agent Affiliation

HEALTHCARE PATIENT AND AGENT AFFILIATION

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History (for agent awareness)

Designation of Agent(s)

Primary Agent Name:

Authority granted to Primary Agent (check all that apply):

Access and receive copies of medical records, including summaries and test results
Receive protected health information by phone, email or secure portal
Schedule, reschedule or cancel appointments on behalf of the patient
Pick up prescriptions and medical supplies
Inquire about billing and insurance information (does not authorize payment obligations)
Discuss and provide non-invasive consent for routine care when patient is incapacitated (medical consent authority may be limited by law)

Alternate Agent

Sensitive Information

The following categories of protected health information are particularly sensitive and require explicit authorization to disclose. Check boxes to permit release to designated agent(s).

Mental health records and psychotherapy notes
Substance use disorder treatment records
HIV-related information and testing results
Genetic testing and counseling records

Limitations, Special Instructions, and Scope

Authorization; HIPAA Acknowledgment

I, the undersigned patient (or legal guardian), hereby designate the individual(s) named above as my authorized agent(s) to receive protected health information and to act on my behalf with respect to the specific authorities checked above. This authorization is given pursuant to applicable health information privacy laws and authorizes healthcare providers, billing agents, and insurers to disclose protected health information to the designated agent(s) for the purposes described herein.

I understand that information disclosed pursuant to this authorization may include medical, mental health, substance use treatment, HIV-related, and genetic information where I have checked authorization for those categories. I understand that once information is disclosed to the designated agent(s), it may be re-disclosed and no longer protected by privacy rules.

This authorization is voluntary. I understand that I may refuse to sign this form and that my refusal will not affect my ability to obtain treatment, payment, or eligibility for benefits unless the information is required to determine benefit eligibility. I have the right to revoke this authorization at any time by submitting a written revocation to the healthcare provider's records department; revocation will not apply to disclosures made in reliance on this authorization prior to receipt of the revocation.

Patient Certification

By signing below I certify that I am the patient named above or the duly authorized legal guardian or representative of the patient, that the information provided in this form is true and correct to the best of my knowledge, and that I have the authority to make this designation. I authorize healthcare providers to rely upon this designation until revoked in writing. I understand that some actions (including major medical decisions) may require additional legal documentation under state law and that this Affiliation does not, by itself, create a general power of attorney unless otherwise executed in a separate instrument.

Provider reliance statement: The healthcare provider and its staff are authorized to act in good faith upon a copy or electronic reproduction of this document and shall not be liable for actions taken in reliance on this designation except for willful misconduct or gross negligence. This designation supersedes any previous informal designations for the purposes stated herein unless otherwise explicitly noted in writing.

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