Consent for My Health Care Agent to Act as My Personal Representative and
Consent for Release of Protected Health Information
I give permission for my Health Care Agent to act as my personal representative for purposes of the
Health Insurance Portability and Accountability Act (HIPAA) of 1996. This includes amendments to
HIPAA during any time that my Health Care Agent is acting on my behalf.
I give my Health Care Agent permission to ask for, receive, or look at any information about my
physical or mental health. I approve that any health care provider, health plan, hospital, clinic,
laboratory, pharmacy, insurance company, or other health care related business can share my
personal health information and medical records with my Health Care Agent. This includes any past,
present or future medical or mental illness regarding my ability to make health care choices. This
permission includes information protected by HIPAA.
I understand my Health Care Agent can sign authorizations, releases, or other records that may be
needed to get this information. My Health Care Agent can also consent for the release of my
information to others. I understand that my Health Care Agent may share this information with
others. This means that my information is no longer protected by HIPAA.
I also have the right to look at any information shared with my Health Care Agent.
I will mark with my initials the information that my Health Care Agent cannot have access to:
_____ Alcohol, drug, and other drug abuse
_____ Behavioral and mental health
_____ Sexually transmitted diseases, AIDS, and HIV-related information
_____ Genetic tests
I understand my Health Care Agent’s access to my personal health information by this form
terminates when I die. I can cancel this permission and consent at any time by sending a letter to my
health care provider.
X _________________________________________ _________ / ________ / ______________
Sign your name Date
Print your name