Health Insurance Appointment of Representative Form

Health Insurance Appointment of Representative Form
Use this form to appoint someone to communicate and act on your behalf for health insurance matters.
Member Information
Member Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Member ID (if applicable)
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Representative Information
Representative Type
Full Name
First NameMiddle NameLast Name
Relationship to Member
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Scope of Authorization
Authorized Activities
Other
Authorization End Date
MonthDayYear
Date
Authority Limitations or Notes
Consent to Act on My Behalf
Verification and Signatures
Member Signature
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Date Signed
MonthDayYear
Date
Representative Acknowledgment Signature
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Witness or Notary Signature
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Should be Empty: