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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Patient Name: DOB: SSN: MR#: Please initial the following: I hereby authorize Lenoir Physicians Network to provide the individuals listed below with

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How to fill out patientpersonal representative request for

01

Step 1: Obtain the patientpersonal representative request form from the healthcare institution or download it from their website.

02

Step 2: Provide your personal information such as your name, address, phone number, and email address in the appropriate sections of the form.

03

Step 3: Clearly state your relationship to the patient for whom you are requesting to be their personal representative.

04

Step 4: Include the name and contact information of the patient on whose behalf you are requesting to be a personal representative.

05

Step 5: Indicate the specific rights and responsibilities you wish to have as a personal representative.

06

Step 6: Sign and date the form, certifying that the information provided is accurate and true to the best of your knowledge.

07

Step 7: Submit the completed form to the healthcare institution either in person, by mail, or through their online portal.

08

Step 8: Follow up with the institution to ensure that your request has been received and processed.

Who needs patientpersonal representative request for?

01

Anyone who wishes to act as a personal representative for a patient needs to fill out a patientpersonal representative request form.

02

This could include family members, close friends, or individuals who have been legally authorized to make decisions on behalf of the patient.

03

A patientpersonal representative request is needed when the patient is unable to make decisions for themselves due to their health condition or legal incapacity.

04

Having a personal representative ensures that someone can advocate for the patient's healthcare needs, make medical decisions, and access their medical records.

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