Personal Representative Form - HIPIOWA 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Type of Information' section. Here, you will authorize the release of your Protected Health Information (PHI) and Protected Financial Information (PFI) to designated individuals.
3. In the 'Authorized Use and/or Disclosure' section, clearly state who can receive your information and for what purpose. Ensure you understand that if these individuals are not healthcare providers, your information may not be protected under federal privacy laws.
4. Next, complete the 'Disclosure Limitations' section if you wish to impose any restrictions on what information can be shared. If left blank, no limitations will apply.
5. Fill in the 'Designation of Authorized Individual(s)' section with names, phone numbers, and privacy passwords for each authorized person.
6. Finally, sign and date the form in the 'Signature and Authorization' section. Make sure to include your printed name and relationship to the member if applicable.

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