ntative, please print and sign your name in the space below Personal Representative (Print) Personal Representative's Signature Relationship For ColumbiaDoctors use only Complete this section if this form is not signed and dated by the patient or patient's personal representative. I have made a good faith

by my Insurance company. I authorize my insurance benefits be paid directly to ColumbiaDoctors for services rendered. I authorize representatives of ColumbiaDoctors to release pertinent medical Information to my insurance company when requested or to facilitate payment of a claim. Notice of Privacy Practices: A