Get Nh Dartmouth-hitchcock Designation Of Personal Representative 2020-2025

Filling out the NH Dartmouth-Hitchcock Designation of Personal Representative form can empower you to designate someone to help manage your health information rights. This guide provides clear, step-by-step instructions to assist you in completing the form online with ease and confidence.

Follow the steps to fill out your designation form correctly.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. In the first section, fill in the name of your designated Personal Representative. Ensure the name is clearly printed to avoid any discrepancies.
3. Next, indicate the relationship of your Personal Representative to you. This could be a partner, sibling, friend, or another role, making sure to use neutral language.
4. Provide the complete address of your Personal Representative, including city, state, and zip code. This information is essential for proper identification.
5. Enter the phone number of your Personal Representative. This is necessary for quick communication regarding your health information.
6. In the section titled ‘Verbal Conversations,’ affirm your permission for the staff at Dartmouth-Hitchcock facilities to discuss your protected health information with the designated individual.
7. Check the boxes that apply to grant your Personal Representative additional permissions, including proxy access to the patient portal and the ability to request copies of medical records.
8. Acknowledge your understanding of the information being shared by signing the form. In the appropriate field, print your name and include the date.
9. If applicable, provide the name of your legal representative in the designated area. This is necessary only if the form is being signed on behalf of the patient.
10. Review all entered information for accuracy before finalizing. Once confirmed, save your changes, download a copy, and print or share the completed form as needed.

Complete your NH Dartmouth-Hitchcock Designation of Personal Representative form online today to ensure your health information is managed according to your wishes.