REGAPP-0130-121117 Auth Rep Form for Appeals-2025

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45 votes

The document is an Authorized Representative Form used to grant an individual permission to file an appeal and communicate with UHA on behalf of a member regarding a specific appeal. It includes sections for member information, details about the authorized representative, and consent for accessing medical information related to the appeal. The form also outlines the right to revoke authorization and specifies that it will expire one year from the date of signature.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (140 Votes)
2017	4.3 Satisfied (45 Votes)

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