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Proxy Form Humana

The member appoints an authorized representative to act on their behalf for any claims or benefits identified in a specific case number. The representative is authorized to receive any information related to the case that is provided to the member and to act for the member in providing information to the health plan regarding disputed claims, approvals, or authorizations. The member signs to appoint the representative, who also signs to accept the appointment and provides their relationship and contact information.

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Mark Ma
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135 views1 page

Proxy Form Humana

The member appoints an authorized representative to act on their behalf for any claims or benefits identified in a specific case number. The representative is authorized to receive any information related to the case that is provided to the member and to act for the member in providing information to the health plan regarding disputed claims, approvals, or authorizations. The member signs to appoint the representative, who also signs to accept the appointment and provides their relationship and contact information.

Uploaded by

Mark Ma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPOINTMENT OF AUTHORIZED REPRESENTATIVE FORM

Member Name

Member ID Number

I,

, appoint
Name of Member

Name of Authorized Representative

to act on behalf of
Name of Member
in connection with any claim for coverage or benefits identified in case # [Insert reference #] including
receipt of any approval(s) or authorization(s) that are required before medical service(s). I authorize my
representative to receive any and all information related to this case that is provided to me, and to act for
me and for my minor dependent, if named above, in providing any information to the group health plan in
relation to the disputed claims, approvals, or authorizations. This document is not intended to authorize
access to any personal health information unrelated to the disputed claims, approvals, or authorizations.

Signature of Member

Address:

Date

Telephone Number:

I,

, hereby accept the above appointment.


Name of Authorized Representative

I am a/an
Relationship to member

Signature of Authorized Representative


Address:

GF-1_AOR

Date
Telephone Number:

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