Section A --- Purpose
This form allows you (the “individual”) to give East West Pediatrics permission (authorization) to disclose your protected health information (PHI) to a person that will act as your Personal Representative. The information covered by this authorization is protected health information, including identification of treating providers of care, diagnoses, procedures, and personal information, such as your date of birth and mailing address.
Each adult family member, including each adult child (age 18 or older, or as determined by state law) who expects to have a relative or friend act as a Personal Representative must complete an authorization form. For example, if you expect your parent to call us on your behalf, you need to fill out this form. If you do not wish to name a personal representative, do not complete this form. You are not required to name a personal representative, but if you do not, we will not release you protected health information to someone who might call or write on your behalf. Your Personal Representative may be anyone of your choosing. You must provide the information in section C for each person before we can treat that person as your Personal Representative.
Please Note: This authorization does not give your Personal Representative authority, either implied or direct, over any treatment or direct care decisions.
Section B --- Individual's information
I authorize East West Pediatrics to treat the person(s) named in Section C as my Personal Representative(s) subject to the rights and restrictions, if any described in Section C.