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Personal representatives form

A Personal Representative may be legally appointed or designated by the member or patient to act on their behalf. For Personal Representatives that have been legally appointed, the Personal Representative can complete this form and attach supporting legal documentation, such as a Power of Attorney that indicates full health care decision-making authority, guardianship documentation, etc. Use this form to identify a person who can make decisions about your healthcare, request and disclose your PHI or exercise your rights on your behalf.

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