Designation of Personal Healthcare Representative Form

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Prospect Medical Systems / For Members / Member Form

Designate Personal Representative

If a patient choses to designate a personal representative to act on behalf of the patient in making healthcare-related decisions and have unlimited access to the patient's information, please download and complete this form.

If the patient is a minor, a parent or legal guardian must sign.

If the patient is unable to sign for any other reason, a legal representative must sign the designation and submit documentation to verify the authority to sign.

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