Personal Representative Request Form

Please correct the errors described below.

This form identifies the person who has legal authority to act on a subscriber’s behalf in making decisions related to the subscriber’s health care. This provision applies to persons with legal guardianship, power of attorney, or other documented legal authority to act on behalf of a subscriber. Questions regarding this form should be directed to the Privacy Official.

Subscriber Information: (individual whose information will be released) Required fields denoted by **

Personal Representative Information

A copy of a Power of Attorney or other court-initiated document must be attached to this form in order for it to be processed. Attach supporting documentation and description (for example: Power of Attorney for health care decisions, Guardianship/Custodial, Executor of Estate)

Signature/Date (The subscriber’s legal personal representative must sign and date this form for it to be processed.)

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

  • The federal Privacy Rule, known as the HIPAA Privacy Rule, requires your health plan to follow certain procedures before providing access to Protected Health Information (PHI) to someone other than the individual who is the subject of the PHI. PHI is information about an individual that can reasonably be used to identify the individual, and that relates to his/her past, present or future physical or mental health or condition, and the provision of health care to the individual or the payments for that care.
  • The health plan will release PHI to an individual’s Personal Representative upon written verification of such status. Acceptance of a Personal Representative will depend on the extent of their legal authority to make health-related decisions on behalf of the individual, such as whether they have Power of Attorney or legal guardianship.
  • The parent of a minor is generally considered to be the minor’s Personal Representative unless otherwise required by applicable law. If the parent is not covered under the minor’s health plan, he/she will need to submit documentation to verify his/her parental status.
  • The health plan will recognize as a Personal Representative an executor, administrator, or a person recognized by law as having authority to act on behalf of a deceased individual or the individual’s estate.
  • The health plan will not however, treat someone as an individual’s Personal Representative if we reasonably believe (1) the individual may be subject to domestic violence, abuse or neglect by the Personal Representative; (2) treating the person as a Personal Representative could endanger the individual; or (3) in the exercise of professional judgment (for example, in a licensed professional’s judgment), the health plan decides that it is not in the individual’s best interest to treat the person as a Personal Representative.
  • A Personal Representative designation will remain in effect until the individual, a court order, or an applicable law revokes it.
  • To assist the health plan in responding to this request, please complete this form by printing or typing into the spaces provided. Attach additional pages if necessary to clarify your request.
  • Mail or fax the completed form and supporting documentation to:

Attn: Privacy Official

If you have any questions about this form, please call the Privacy Official.

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