Plan authorized 2026

1. Click ‘Get Form’ to open the plan authorized document in the editor.
2. Begin by filling out your personal information in the designated fields, including Member Name, Address, Date of Birth, Phone Number, and Member ID.
3. In Section One, list up to three authorized representatives. For each representative, provide their name, address, phone number, and relationship to you.
4. Proceed to Section Two and select the type of protected health information (PHI) you wish to disclose. Choose one option that best fits your needs.
5. If applicable, complete Section Three by initialing next to any sensitive PHI you want discussed. This is crucial for mental health or substance use disorder information.
6. In Section Four, check at least one method of disclosure—either verbally or written—to specify how your representatives can receive information.
7. Review Section Five carefully before signing. Ensure you understand the expiration and revocation details before finalizing your authorization with your signature and date.

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