HR Patient Advocate Form

HR Patient Advocate Form

Use this form to designate an individual (Patient Advocate) to receive health- and benefits-related information and to assist in communications between the Employer, occupational health providers, benefits administrators, and medical providers. This designation does not, by itself, create a durable power of attorney for health care; it is a limited authorization for communication and assistance as described below. To revoke this designation, follow the revocation procedure stated herein.

Personal Information

Position Information

Patient Advocate Designation

I hereby designate the individual named below to act as my Patient Advocate for the limited purposes stated in this form. This designation authorizes the Employer, its occupational health units, benefits administrators, and medical providers to communicate with and release information to the designated Patient Advocate in accordance with the scope selected below.

Scope of Authorization (select all that apply)

Authorize release of medical and occupational health information to the Patient Advocate for purposes of treatment coordination, return-to-work planning, leave administration, and benefits claims.

Authorize the Patient Advocate to attend medical appointments, meetings with Employer representatives, and benefits consultations on my behalf.

Authorize the Patient Advocate to make non-binding care coordination decisions and assist in selecting providers, scheduling care, and managing communications with insurers and benefits administrators as directed by me.

Authorize the Patient Advocate to communicate with insurance carriers and benefits administrators to obtain claim information, status updates, and to submit required documentation.

Authorize the Patient Advocate to access employment-related medical records held by the Employer's occupational health or benefits departments to the extent permitted by applicable law.

Effective Period and Revocation

Revocation: I understand that I may revoke this designation at any time by submitting a written revocation to Human Resources. Revocation will take effect upon receipt and processing by Human Resources. The Employer may also terminate recognition of the Patient Advocate if the Advocate engages in conduct that interferes with medical care, violates confidentiality obligations, or otherwise reasonably prevents performance of duties described herein.

Confidentiality and Privacy

By signing below I provide my informed consent for the release and communication of my protected health information to the Patient Advocate for the purposes described above, to the extent permitted by applicable health information privacy laws. I understand that the Employer will make reasonable efforts to limit disclosures to information necessary for the stated purposes. The Patient Advocate is expected to maintain the confidentiality of information received and may be subject to disciplinary action for unauthorized disclosure.

Authorization to Contact Previous Employers and Conduct Checks

I authorize the Employer and its agents to contact prior employers listed below for verification of employment and other job-related information, and to conduct background or credential checks where job-related and permitted by law. This authorization is for the purpose of verifying information provided and for determining suitability for any accommodation or benefits relevant to the Patient Advocate relationship.

Employment History (Most Recent)

Employment History (Previous)

Education

References (Professional)

Legal Disclosures

At-Will Employment: Nothing in this designation alters the at-will employment relationship between the Employee and the Employer. Either the Employee or the Employer may terminate employment at any time, with or without cause, subject to applicable law.

Equal Opportunity: The Employer is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other protected characteristic. Requests for reasonable accommodation related to the Patient Advocate designation will be considered in accordance with applicable law.

Applicant Certification and Authorization

I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. I authorize the Employer and its designated agents to disclose and discuss my health, benefits, and employment-related information with the Patient Advocate as set forth above. I understand that disclosures made in good faith under this authorization are not a breach of the Employer's duty of confidentiality. I further authorize the Employer to contact prior employers and to conduct background or credential checks as described in this form.

I understand that this form is a limited authorization for communication and assistance only and does not automatically grant the Patient Advocate any legal authority to make binding health care decisions unless I have executed a separate, valid legal instrument that confers such authority under applicable law.

I consent to the Employer contacting prior employers and conducting background/credential checks where permitted and relevant to the administration of benefits, accommodations, or the Patient Advocate designation.

Acknowledgment

By signing below I acknowledge that I have read, understand, and accept the terms of this Patient Advocate designation and the authorizations herein. I understand the limitations of this designation and accept responsibility for notifying Human Resources in writing if I wish to revoke or modify this designation.

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