This form may be used to notify Express Scripts of a personal representative for the individual identified in Section I, below 2025

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, provide your personal details including your name, gender, date of birth, member number, group number, address, and contact telephone number. Ensure all information is accurate.
3. Move to Section II and enter the personal representative's information. Include their name, gender, date of birth, relationship to you, address, and contact number.
4. In Section III, confirm your designation of the personal representative by signing and dating the form. Remember that this authorization allows them access to your health information.
5. If applicable, complete Section IV by having the personal representative sign and date the form. Attach any necessary legal documentation that supports their authority.

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