Medicare Advantage Designation of an Authorized Representative I appoint the individual listed below to act as my representative in connection with my claim, grievance or asserted right under Title XVIII of the Social Security Act (the Act) and related provisions of Title XI of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to the representative indicated below. The member named below should be the person signing this designation and consenting to the release of information. If the member is a minor, a parent or legal guardian must sign. If the member is unable to sign for any other reason, a legal representative must sign the designation and submit documentation to verify the authority to sign. *Indicates a required field Member Information First Name Last Name Date of Birth Email (optional) Phone Number Street Address Apartment or Unit Number (optional) City - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Enter a three-character prefix, then numerical digits Member ID Authorized Representative Information First Name Last Name Professional status or relationship e.g. child, attorney, etc. - Select -SpouseSon/DaughterAttorneyFriendOther Relationship to member Relationship to member - Other Phone Number Email Email Confirm Email Address Street Address Apartment or Unit Number (optional) City - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code 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 (Member must designate specific reason for disclosure of this sensitive information) To assist with claim(s) payment (Including FSA, HRA, HSA, and Coordination of Benefits) Coordination of care Assist with treatment Other Please specify a reason. 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. I understand this designation is valid for 1 year. I may revoke this designation at any time within the year by notifying Blue Cross. I understand that a revocation will not apply to information that was already disclosed. I understand that once information has been disclosed according to these instructions, the Health Insurance Portability and Accountability Act (HIPAA) and other privacy laws may no longer protect the information. Blue Cross may request information, now or in the future, as it deems necessary to confirm authorized representative status. documentum_id data_send_successfully_to_form_api Submit Contact Information If you do have questions, call us at 1-800-200-4255 (TTY: 711). April 1 through September 30 8:00 a.m. to 8:00 p.m. ET Monday through Friday October 1 through March 31 8:00 a.m. to 8:00 p.m. ET Seven days a week