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Authorized-Representative-Request-Form. Accessible PDF 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the FAX Number and Member Name at the top of the form. Ensure that the Aetna ID Number is accurately filled in for identification purposes.
- In the 'Provider of Service' section, specify the name of the service provider along with the relevant dates of service or proposed service.
- Clearly print your name in the designated area to authorize someone to act on your behalf. This person will be referred to as your authorized representative.
- Select whether you are requesting a complaint or an appeal by checking the appropriate box.
- Review and check any boxes regarding disclosure of Protected Health Information (PHI) as per your preferences, ensuring you understand what information may be shared.
- Sign and date the form at the bottom, and if applicable, indicate your relationship to the member if you are not signing as them.
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What is the CMS 1696 authorization form used for?
Appointment of Authorized Representative Use this form to appoint an individual or organization as your Medi-Cal authorized representative. Your authorized representative may act for you on all duties related to your Medi-Cal eligibility and enrollment. Or, you may also limit duties.
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Requests must be submitted 48 hours in advance and may only be submitted by authorized represenetives of respective departments. office at (401) 277- 4968
Such distribution shall be pursuant only to a written request by the Class 3a facility indicating the name and address of the facility, the name and address ofRead more
Open PDF file, 278.29 KB, Request to Choose Someone to Be My Authorized Representative (Image-10) (English, PDF 278.29 KB). Open DOCX file, 100.54 KBRead more