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The Health Insurance Portability and Accountability Act HIPAA of 1996 45 CFR 164. 502 g FC-11192012-M-001. 888. 781. 4371. Signature of parent/legal guardian/member giving authorization Today s Date Mail this form to Advicare Attn Compliance Officer 532 South Main Street Greenville SC 29601. If you want more than one representative you must fill out more forms. Name of representative Relationship to Member name Member ID Date of birth member Limiting the Amount of Information Provided Please...

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What is choosing a personal representative?

Choosing a personal representative involves selecting an individual to manage and distribute your estate after your passing.

Who is required to file choosing a personal representative?

The individual creating the estate plan is required to file choosing a personal representative.

How to fill out choosing a personal representative?

To fill out choosing a personal representative, you must select a trustworthy individual and formally designate them in your estate planning documents.

What is the purpose of choosing a personal representative?

The purpose of choosing a personal representative is to ensure that your assets are managed and distributed according to your wishes after your death.

What information must be reported on choosing a personal representative?

When choosing a personal representative, you must report the individual's name, contact information, and relationship to you.

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