personal representative letter text

Appointment of personal representative for [elided]

To whom it may concern:

I am [elided]. My date of birth is [elided]. I reside at [elided], otherwise known as [elided]. My telephone number is [elided].

With this letter, I hereby appoint as my personal representative my nephew, Jonathan Kamens, who resides at [elided], with the telephone number [elided].

I hereby authorize any and all entities in possession of protected health information about me to disclose said information without limitation to my personal representative upon his request.

Furthermore, I require my personal representative to be included in all discussions with me about my care, including but not limited to “rounds” and other conversations about my care with doctors and nurses on my care team. When my personal representative cannot be present in person for these discussions, he should be included via a telephone call to [elided]. Including my personal representative in care discussions is essential to my care, and therefore it is essential for it to be done reliably and consistently by my care team.

All members of my care team must be informed about this requirement. Furthermore, when I am being treated in an inpatient setting, this requirement should be posted prominently, with my personal representative’s name and telephone number, in my room.

I release any care provider to whom I provide this letter from any liability deriving from disclosing any information to my personal representative. I understand that the information disclosed to my personal representative may be re-disclosed by him and would then no longer be protected by federal privacy regulations.

This letter satisfies HIPAA requirements and should be considered a sufficient replacement for the equivalent form used by any HIPAA-covered entity, including both care providers and insurance companies. Because my personal representative cannot always be present in person to fill out a specific form, and because time is often of the essence in these matters, requiring me or and my personal representative to fill out a specific form rather than this letter is an undue burden and an unacceptable impediment to my care.

This letter is not intended to be a health care proxy. However, upon admission to any inpatient care setting, if there is not already a health care proxy on file designating Jonathan Kamens as my health care agent, I should be given the opportunity to complete one.

Signed:

________________________________________    Date: ______________________________
[elided], covered individual

________________________________________    Date: ______________________________
Jonathan Kamens, personal representative