How to Fill Out and Submit the Wellstar Patient Communication Form

The Wellstar Patient Communication Designation form is a one-page authorization that lets Wellstar Health System share your medical or billing information with specific people you name, such as a spouse, adult child, or trusted friend. Without it, federal privacy rules under HIPAA keep your records closed to anyone you haven’t given written permission to receive them. You download the PDF from Wellstar’s website, fill in who may receive what, sign it, and turn it in at the Wellstar location where you get care.¹

Where to Get the Form

Wellstar hosts the PDF on its website under practice forms for Wellstar Medical Group locations.¹ You can also ask for a blank copy at the front desk of any Wellstar facility. The form applies across Wellstar’s hospitals, clinics, and medical group offices in north and west Georgia.²

One boundary to be aware of: this form is not the same as MyChart proxy access. If you want someone to log in to your MyChart account and view records directly, Wellstar uses a separate Adult Proxy Form and Release of Information Authorization Form available through the MyChart FAQ page.³ The Patient Communication Designation form covers Wellstar’s own outbound disclosures to the people you list, not portal logins.

What to Have Ready Before You Start

The form is short. Have these details in front of you:

Your full legal name (last, first, middle initial) and date of birth in month/day/year format.
Your mailing address, including apartment or P.O. box.
Your Wellstar medical record number if you have it. It’s optional, but it helps staff match the form to your file faster. Social Security number is also optional.
For each person you want to authorize: full name, phone number, and relationship to you. The relationship is required for anyone listed under the “Other” category.

All of these fields appear on the form itself.¹

Filling Out the Form

Patient Information

Print your legal name, middle initial, date of birth, and complete mailing address at the top. Enter your medical record number if you know it. You can leave the Social Security number blank.¹

Who You Are Authorizing

The form has pre-labeled lines for a spouse and children, each with space for the person’s name and phone number. A separate “Other” section lets you add anyone else, such as a sibling, close friend, or caregiver, with a required field for how they relate to you.¹ You can list multiple children and multiple other contacts on a single form.

What Information They Can Receive

Three disclosure categories appear as checkboxes:

All Billing / Account Information covers statements, balances, and payment details.
All Medical Information covers clinical records, visit notes, and diagnoses.
Laboratory Results covers lab test outcomes.

Check one, two, or all three.¹ The same scope applies to everyone named on that form. If you want your spouse to see only billing but your adult child to see everything, use two separate forms with different boxes checked.

Duration and Signature

The form doesn’t ask for an expiration date. The authorization stays in effect until you revoke it in writing.¹ Sign and date the bottom. Federal regulations require both a signature and a date for a HIPAA authorization to be valid.⁴

How to Submit It

The form’s own revocation language refers to “the Wellstar location where I received care,” and the same location handles the original submission.¹ Hand the signed form to front desk staff at the facility where you’re a patient. In-person delivery gets it scanned into your record immediately.

Wellstar also maintains a fax line for its Health Information Management offices at 770-810-4193, and each hospital has a mailing address for HIM Release of Information.⁵ Those channels are listed primarily for medical records requests, but they go to the department that handles authorization paperwork. If you fax or mail the form, keep a copy and call the facility a few days later to confirm receipt.

There is no indication the form can be submitted electronically through MyChart. The portal handles a different authorization workflow for proxy account access.³

Designated Contacts Are Not Decision-Makers

The people you name on this form can receive the categories of information you checked. They cannot make medical decisions for you, request amendments to your records, or authorize further disclosures. Those powers belong to a personal representative, which under HIPAA means someone with a healthcare power of attorney, a court-appointed guardianship, or parental authority over a minor. A personal representative “stands in the shoes” of the patient.⁶

If someone already holds a healthcare power of attorney or legal guardianship over you, they may not need this form. Their legal authority already entitles them to your protected health information. The communication designation form is for people without that legal standing whom you want kept in the loop.

Revoking the Authorization

You can cancel at any time. The form states that revocation must be in writing and presented to the Wellstar location where you received care.¹ Federal rules confirm that any HIPAA authorization can be revoked in writing, with revocation taking effect once the provider receives it.⁴

Revocation isn’t retroactive. Anything Wellstar shared while the authorization was active stays disclosed. To remove just one person from a list while keeping the rest, submit a new form naming only the contacts you still want authorized, along with a written request revoking the earlier version.

Information the Form May Not Fully Cover

Some categories of health information carry extra federal protections, and checking “All Medical Information” may not reach them.

Psychotherapy Notes

Under HIPAA, psychotherapy notes are kept separate from the rest of your medical record and require their own specific authorization before anyone can see them, even for treatment purposes.⁷ A general communication designation form typically does not meet that separate requirement. Ask the mental health provider for the specific form if you want a contact to receive those notes.

Substance Use Disorder Records

Records from substance use disorder treatment programs fall under 42 CFR Part 2, which imposes its own consent requirements beyond standard HIPAA authorizations.⁸ A Part 2 consent must include specific elements like a description of the information, named recipients, the purpose, and a statement about redisclosure. The Wellstar communication designation form is unlikely to meet all of those on its own.

If Wellstar Discloses Without Authorization

If Wellstar shares your information with someone you didn’t authorize, or keeps disclosing after you revoked, you can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. Complaints can be submitted electronically through the OCR Complaint Portal or in writing.⁹ You have 180 days from when you became aware of the violation to file, though OCR can extend that deadline for good cause.¹⁰ Filing costs nothing and does not require a lawyer.

1
Wellstar Health System. Patient Communication Designation
2
Wellstar Health System. Wellstar Health System
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Wellstar Health System. MyChart Frequently Asked Questions
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eCFR. 45 CFR 164.508 – Uses and Disclosures for Which an Authorization Is Required
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Wellstar Health System. Request Your Medical Records
6
U.S. Department of Health and Human Services. Guidance – Personal Representatives
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U.S. Department of Health and Human Services. HIPAA Privacy Rule and Sharing Information Related to Mental Health
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eCFR. 42 CFR Part 2 – Confidentiality of Substance Use Disorder Patient Records
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U.S. Department of Health and Human Services. Filing a Health Information Privacy Complaint
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U.S. Department of Health and Human Services. How to File a Health Information Privacy or Security Complaint