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01. Edit your authorization of representative form online
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How to use or fill out the Appointment of Authorized Representative Form
- Click ‘Get Form’ to open it in the editor.
- Begin by entering your printed name in the designated field at the top of the form, followed by your UnitedHealthcare Member ID Number and Date of Birth.
- In the section labeled 'I want to allow', clearly print the name of your chosen authorized representative.
- Review the list of permissions provided. Check all applicable boxes that grant your representative authority to discuss health information, make changes to your Primary Care Provider, request appeals, and fill out necessary forms.
- Sign the form as either a member or legal representative. If applicable, print the legal representative's name below your signature.
- Complete your address details including city, state, zip code, and telephone number.
- Finally, ensure today's date is filled in and have the document notarized before submission.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2013 | 4.8 Satisfied (32 Votes) |
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