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 our facility as well as to establish the next of kin. Please upload a copy of the official death certificate as supporting information. Also, the request must be completed by the next of kin per the hierarchy for the executor of the estate or distributee and proof uploaded.
If the patient is incapacitated, unable to sign for him or herself and there is a personal representative who is legally responsible then that individual will sign 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 authorization form.
If the patient is a minor over twelve (12) and under eighteen (18) who must sign:
The parents or legally appointed guardian
If the patient is an emancipated minor (married or self-supporting and living apart from the parent’s residence) he/she may sign
For non-behavioral health Patient Access requests both a parent or legally appointed guardian and minor must sign
For behavioral health requests including Patient Access the minor must sign