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AUTHORIZATION FOR DESIGNATED REPRESENTATIVE For the Disclosure of Protected Health Information Member Name: Member ID or Date of Birth: Address: Street, City, State & Zip Code Effective Date of Authorization:

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How to fill out authorization for designated representative

01

Start by entering the date on the top right corner of the form.

02

Fill out your personal information, such as your name, address, and contact information, in the designated fields.

03

Provide the name and contact information of the person you are authorizing as your designated representative. Make sure to include their full name, address, and phone number.

04

Specify the reason for the authorization. This could be related to medical, legal, or financial matters, or any other specific purpose.

05

Include the duration of the authorization. Indicate when the authorization begins and when it expires.

06

Sign and date the form at the bottom to confirm your consent and agreement.

07

Make a copy of the completed authorization form for your records, and provide the original to the designated representative or the relevant authority.

Who needs authorization for designated representative?

01

Individuals who are unable or prefer not to handle certain tasks or make decisions on their own behalf may need to authorize a designated representative. This could include individuals with physical or mental disabilities, elderly individuals who require assistance, individuals facing legal proceedings, or individuals who are unable to be physically present for certain actions or transactions.

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