Legal Representative form

Member Information

First Name

Last Name

Date of Birth

e.g. MM/DD/YYYY

Email (optional)

Phone Number (optional)

e.g. (000) 000 - 0000

Street Address (optional)

Apartment or Unit Number (optional)

City (optional)

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LEGAL REPRESENTATIVE ACKNOWLEDGEMENT

By checking this box, I certify that the information on (and attached to) this form is true and accurate to the best of my knowledge. I understand that Blue Cross may request information, now or in the future, as it deems necessary to confirm my Legal Representative status. I understand the designation of legal representative will remain in effect only for as long as the legal authority upon which it is based remains valid.

Member Information

Upload required documents

LEGAL REPRESENTATIVE ACKNOWLEDGEMENT

Contact Information

Medicare Advantage Contact information

Medex Contact information