Personal Representative Request Form

The HIPAA Privacy Rule requires MedCost to follow certain procedures before it may provide access to your Protected Health Information (PHI) to someone other than you. PHI is information about you that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, and the provision of health care to you or the payments for that care.

You have the right to authorize that the PHI held by MedCost be released to and/or received by persons or organizations you identify. The person or organization you identify on the Personal Representative Request Form may not be subject to the HIPAA Privacy Rule. If this is the case, your appointed Personal Representative may further release your confidential information without protection from federal or state privacy laws.

To complete a Personal Representative Request Form choose from one of the file types listed.

• Word Document
• PDF