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The document is an Authorized Representative Request form that allows a member to designate someone to act on their behalf in requesting services or filing complaints and appeals with Aetna. It includes sections for member information, the authorized representative's details, and consent for the disclosure of Protected Health Information (PHI). The form outlines the implications of signing, including the potential redisclosure of PHI and the member's rights regarding enrollment and benefits.
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The acronym AOR stands for agent of record. It is a document an agent would have a potential client sign to give the agent access to his or her health insurance policy through the carrier.
An agent of record letter (also called a broker of record letter or BOR letter) is a document that formally designates an individual or entity as the AOR for an insurance policy. It grants the AOR authority to represent the insured party or policyholder when negotiating plan details with insurance companies.
An authorized representative is the person you choose to help with or handle affairs related to your health care services. This can be a Power of Attorney, a family member, friend, caregiver or an advocate.
An Authorized Representative can be family members, friends, or any other individual you choose. For example, you may want your spouse or adult child to help with billing questions, booking appointments, or to be aware of your health status. Am I required to have an Authorized Representative? No.
To authorize DHS to release information about the traveler to a third party, including someone serving as a representative for the traveler, the traveler must complete and return the DHS Form 590.

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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.
by. An agent of record (AOR) is the individual health insurance agent you designate with your health insurance company to represent you and help you manage your insurance policy. Each individual policy you purchase has its own agent of record.

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Authorized Representative Form

AUTHORIZED REPRESENTATIVE FORM The above listed authorized representative can release, furnish, provide, exchange and request any and all information.

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Instructions for Form 5307 (Rev. June 2014)

Jun 10, 2014 The application must be signed by the employer, plan administrator, or authorized representative. Note. Stamped signatures are not acceptable.

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