Medex Member Designation of an Authorized Representative

MEMBER INFORMATION

First Name

Last Name

Date of Birth

e.g. MM/DD/YYYY

Email (optional)

Phone Number

e.g. (000) 000 - 0000

Street Address

Apartment or Unit Number (optional)

City

Member ID

Enter a three-character prefix, then numerical digits.

Authorized Representative Information

Relationship to Member

Professional status or relationship, e.g. child, attorney, etc.

First Name

Last Name

Date of Birth

e.g. MM/DD/YYYY

Email

Phone Number

e.g. (000) 000 - 0000

Street Address

Apartment or Unit Number (optional)

City

Information That Blue Cross May Disclose

If “all my information” is not checked above, I authorize Blue Cross to disclose only the following specific information, excluding sensitive information (unless approved below). (Check all boxes that apply).

I approve the disclosure of the following types of sensitive information by Blue Cross (check all boxes that apply):

HIV or AIDS

Mental or behavioral health

Alcohol and substance abuse.
(If Alcohol and substance abuse is checked, you must choose at least one reason for disclosure of this sensitive information.)

Date Your Designation Expires

Please select one

One year from the date of signature.

Other

Member or Legal Representative Acknowledgement

By checking this box, I acknowledge that I have read the contents of the form. I understand, agree, and allow Blue Cross to discuss and/or disclose my information as I have stated above. I understand that Blue Cross does not require that I sign this form in order for me to receive treatment or payment or for enrollment or eligibility benefits. I understand I am entitled to a copy of this form and agree that a photocopy is as valid as the original.

Providing your email address will allow us to send you communications and updates on your designee.

All fields are required unless noted optional.