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Member Authorization Form for a Designated Representative to Appeal a Determination TO: Clinical Appeals Department 48 Monroe Turnpike Trumbull, CT 06611 DATE: Member Name: Member ID #: I hereby authorize

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What is member authorization form for?

The member authorization form is used for granting permission or consent to allow someone to act on behalf of a member.

Who is required to file member authorization form for?

Any member who needs someone else to act on their behalf will be required to file a member authorization form.

How to fill out member authorization form for?

The member or their authorized representative must fill out the form with accurate and complete information.

What is the purpose of member authorization form for?

The purpose of the member authorization form is to officially give permission for someone to represent the member.

What information must be reported on member authorization form for?

The form must include the member's information, the representative's information, and details about the authorization being granted.

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