Your geaux-to for
Primary Care

Designation of Personal Representative

Please use this form to designate a personal representative to act on your behalf in making healthcare related decisions and unlimited access to the patient’s information.

The patient named should be the person signing this designation and consenting to the release of information. If the patient is a minor, a parent or legal guardian must sign. If the patient is unable to sign for any other reason, a legal representative must sign the designation and submit documentation to verify the authority to sign.

For questions, please feel free to request an appointment or contact us.