Medicare Advantage 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

Email

Confirm Email

Please be aware that your Authorized Representative will receive emails from our secure email service. Our security measures are necessary to keep members' information safe.

Phone Number

e.g. (000) 000 - 0000

Street Address

Apartment or Unit Number (optional)

City

Information That Blue Cross May Disclose

By checking the box below, I grant Blue Cross permission to discuss with or disclose to my authorized representative on my behalf:

All my information:
This may include a diagnosis (name of illness or condition), procedure (type of treatment), claims, doctors and other health care providers, and financial information (like billing and banking). This also includes appeals and grievances, claims and payment, eligibility and enrollment, pharmacy, benefits and coverage, dental, financial, billing, diagnosis and procedure, and medical records.

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.)

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.

documentum_id

All fields are required unless noted optional.

Medicare Advantage Designation Of An Authorized Representative

Member Information

Authorized Representative Information

Information That Blue Cross May Disclose

Member or Legal Representative Acknowledgement

Contact Information