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How to use or fill out MEBA Medical Plan Designation of Authorized Representative
- Click ‘Get Form’ to open it in the editor.
- Begin by entering your personal information in Section 1. Fill in your name, address, Social Security number, telephone number, and email or facsimile. If you are not the covered employee, provide the participant's details as well.
- In Section 2, designate your representative by filling in their name, address, telephone number, email or facsimile, and relationship to you.
- Section 3 requires you to specify the claim for which you are authorizing your representative. Choose between a specific claim or services rendered and provide the necessary details such as provider name and date.
- In Section 4, indicate that all communications regarding your claim should be sent to your representative instead of you.
- Finally, sign and date the form at the bottom. Ensure that both this form and the attached Designation of Health Information Recipient are returned to the specified address.
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