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Authorization of representative form

Representative form 2026

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32 votes

The document is an 'Appointment of Authorized Representative Form' for UnitedHealthcare Community Plan members, allowing them to designate someone to act on their behalf. It requires completion by the member or their legal representative, must be signed and notarized, and outlines the powers granted to the representative, including discussing health information and making changes to healthcare arrangements.

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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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