Patients Forms:

Download our new patient forms below to complete your new patient paperwork prior to your appointment.

Step 1 of 6

PATIENT AUTHORIZATION FOR PERSONAL REPRESENTATIVE

Please print all information, then sign and date at the bottom.
Patient Name(Required)
Address(Required)
MM slash DD slash YYYY

Purpose of Request

I authorize the Practice to disclose or provide my protected health information to the following individual, who is authorized to act as my personal representative for the purposes of receiving all of my protected health information. I will inform my personal representative of the last four digits of my social security for identification purposes when inquiring about my health information. As my personal representative, they may exercise my right to inspect, copy, and request amendments to my protected health information. They may also consent or authorize the use or disclosure of my protected health information:

Name of Personal Representative:

Description of Information to be Disclosed

I authorize the Practice to disclose all of my protected health information to my designated personal representative

Expirations or Termination of Authorization

This authorization will remain in effect until terminated by you, your personal representative or another individual (s) of legal entity authorized to do so by court order or law.

Right to Revoke or Terminate

As stated in our Privacy Notice, you have the right to revoke or terminate this authorization by submitting a written request to our Privacy Manager. This can be done in-person or by mailing a request to:

Consultants in Gastroenterology

Attn: Privacy Manager 131 Summerplace Drive West Columbia, SC 29169

Redisclosure

I understand the Practice has no control over the person(s) I have listed as my personal representative. Therefore, any protected health information disclosed under this authorization will no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the Practice.

Address

131 Summerplace Drive, West Columbia, SC
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