Request for Representative 2026

1. Click ‘Get Form’ to open the Request for Representative in the editor.
2. Begin by filling out the 'Identification of Patient' section. Enter your name, date of birth, social security number, and member ID card number. If applicable, include the subscriber's name if it differs from yours.
3. Next, move to the 'Representative Information' section. Ask your chosen representative to provide their name and date of birth in the specified 8-digit format.
4. In the 'Verification Questions for Personal Representative' section, ensure that your representative is prepared to confirm their identity by providing your details as well as their own date of birth.
5. Finally, complete the 'Signature and Notarization' section. Sign the form and have it witnessed by a CMG staff person or notarized. Remember that notary services are often available for free at banks.

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