Appointing A Representative

You May Assign Someone to Work With Us On Your Behalf

If you want a friend, relative, your doctor, or another person to represent your healthcare wishes for you, you can give that person permission to submit coverage determinations, exceptions, and appeals on your behalf. You must complete this form, and it must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

Download Appointment of Representative Form*
Descargar Nombramiento de un Representant

To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader* software on your computer.

*When you click this link, you will leave our website.

 

There may be someone who is already legally authorized to act as your representative under State law. This person would already have permission to work with our plan on your behalf.


H9585_117_092015_Approved
Last Updated 10/09/15