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Use this form to authorize an individual to file an internal UHA appeal and communicate on your behalf with UHA on 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your Member Name, Phone Number, Address, and Member Number in the designated fields. Ensure all information is accurate.
- Provide the Name and Address of the authorized representative who will appeal on your behalf. Include their Relationship to you as the member.
- If applicable, check the box authorizing UHA to disclose sensitive medical information related to HIV, substance use, or mental health treatment.
- State the Reason for appointing your authorized representative and include Date(s) of service along with a Description of service(s).
- Review the section regarding your right to revoke this authorization. Make sure you understand its implications before signing.
- Sign and date the form at the bottom. If you are signing as a personal representative, attach necessary documentation and provide your phone number.
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Related links
Complete all forms required by your health insurer. Or you can write to your insurer with your name, claim number, and health insurance ID number.
They have one week to respond using the Maxient Student Response Form to appeal for review, finding and/or sanction.