If the patient is deceased, please note a copy of the death certificate will be required to verify that patient is deceased when he or she did not expire in one of our facilities. Please upload a copy of the official death certificate, letters of administration or a notarized affidavit that the requestor is a distributee of the deceased if no executor is appointed, and a HIPAA Authorization signed by the executor or distributee as supporting information.
If the patient is incapacitated, unable to sign for themself and there is a personal representative who is legally responsible for the patient, then that individual can sign a HIPAA Authorization on behalf of the patient.
If the patient is a minor under twelve (12), we will request that the parent or legal guardian sign the HIPAA Authorization form.
If the patient is a minor twelve (12) or over and under eighteen (18) the HIPAA Authorization must be signed by:
- The parents or legally appointed guardian of the minor
- If the patient is an emancipated minor (married, pregnant, or a parent of a child) they can sign
- For reproductive health services, either both a parent/legally appointed guardian or a minor can sign