Canadian Meds USA
DESIGNATION OF PERSONAL REPRESENTATIVE
(Limited Power of Attorney)
Note: This form is designed to comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). You have the right to change or revoke this Designation of Personal Representative at any time by written notice mailed or faxed to Canadian Meds USA. Please mail or fax this page as follows: Canadian Meds USA, 11757-F W. Ken Caryl Ave. # 317, Littleton, CO 80127-3719. Toll-Free Fax No: 1-877-933-3625. If you have any questions about this form, please call Canadian Meds USA Toll-Free at 1-877-933-0505.
I, _______________________________________, whose current address is

 _______________________________________________________________________________.

hereby designate (please print full name) ____________________________________ as my Personal Representative for purposes of all rights, obligations and responsibilities under the HIPAA Privacy Rules related to my prescription drug medical information created, maintained on file or used by Canadian Meds USA and TCDS

I acknowledge and agree that Canadian Meds USA and TCDS may disclose my Protected Health Information, including directly related financial information, to my designated Personal Representative. Additionally: (please check one of the following)
My Personal Representative has GENERAL AUTHORITY to authorize either or both Canadian Meds USA and TCDS to disclose my Protected Health Information to other parties on a case-by-case basis.
My Personal Representative does NOT have authority to authorize the use or disclosure of my Protected Health Information by Canadian Meds USA and TCDS to any other parties.
The authority of my Personal Representative to authorize the use or disclosure of my Protected Health Information to anyone other than Canadian Meds USA and TCDS shall be LIMITED as follows:
Personal Representative Contact Information:

Relationship (example: son or daughter)_______________________________________________ .

_________________________________________________________     ____________________.
Street Address                                                                                               Apt. No. (if applicable)

____________________________________     ___________________     ________________.
City                                                                       State                                  Zip Code 

______________________________     _______________________________________________.
Telephone No.                                          Email Address (if available) 

______________________________     _______________________________________________.
Date                                                         Signature of Patient