Form for personal representative 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section A, enter your Member Information. Fill in your first and last name, address, telephone number, Member ID number, email address, and Social Security number.
3. Proceed to Section B to specify the Type of Information you wish to share with your Personal Representative. Select the relevant health information categories that can be disclosed.
4. In Section C, authorize the use and disclosure of your personal health information by providing details about who can access this information as outlined in Section D.
5. Complete Section D by entering the Personal Representative's name, address, phone number, and their relationship to you.
6. Review Section E regarding expiration and revocation of this authorization. Ensure you understand your rights concerning this authorization.
7. Finally, sign and date the form in Section F to confirm your authorization. Make sure to return the signed form as instructed.

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