Authorized personal representative 2026

1. Click ‘Get Form’ to open the Authorized Personal Representative form in the editor.
2. Begin by filling out Section A, Member Information. Enter the Member Name, ID, Date of Birth, and contact details including Home Phone Number and E-mail address. Ensure all required fields are completed.
3. Proceed to Section B for Authorized Personal Representative Information. Fill in the Name, Date of Birth, Mailing Address, and contact numbers. Specify the relationship by checking the appropriate box.
4. In Section C, Scope of Authorization Details, initial next to each type of Protected Health Information (PHI) that can be discussed with your representative. Be sure to check any specific categories you wish to include.
5. Review Section D for Required Signatures. Both the member and personal representative must sign and date the form. If someone else is submitting it on behalf of the member, complete their information as well.

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