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STATEMENT OF REPRESENTATIVE I ___, appoint ___ (Members name) (Representatives name) to act as my representative for matters related to my enrollment and membership in Care Connect + Medicare (HMO
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Start by downloading the statement of representative form from the official website.
02
Read the instructions carefully to understand the requirements.
03
Fill in your personal details such as your name, address, and contact information.
04
Provide information about the person you are representing, including their name and contact details.
05
Clearly state the purpose of your representation in the designated section.
06
If required, attach any supporting documents that validate your authority to act as a representative.
07
Review the completed form for accuracy and completeness.
08
Sign and date the form before submitting it as directed.
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Keep a copy of the filled-out form for your records.

Who needs statement of representative?

01
A statement of representative is needed by individuals who are authorized to act on behalf of another person in legal or administrative matters.
02
This includes attorneys, legal representatives, guardians, or any person who has been given power of attorney by the individual they are representing.
03
The statement of representative serves as documentation of the representative's authority to act on behalf of someone else.
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The statement of representative is a document that designates an individual or entity to act on behalf of another party.
Individuals or entities who have been designated as representatives by another party are required to file a statement of representative.
The statement of representative can typically be filled out by providing the necessary information about the representative, the represented party, and the scope of the representation.
The purpose of the statement of representative is to formally authorize and document the relationship between a representative and the represented party.
The statement of representative typically requires information such as the names and contact information of both parties, the scope of the representation, and any relevant dates.
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