Fill and Sign the Personal Representative Request Form

PLEASE KEEP A COPY OF THIS FORM AND THE INSTRUCTIONS FOR YOUR RECORDS Personal Representative Request Form (Please Print) This form identifies the person who has legal authority to act on a subscriber’s behalf in making decisions related to the subscriber’s health care. This provision applies to persons with legal guardianship, power of attorney, or other documented legal authority to act on behalf of a subscriber. Questions regarding this form should be direct ed to the Privacy Official at _________________ . Subscriber Information: (individual whose information will be released) Required fields denoted by ** Name: (First, Middle, Last, Title)** Date of Birth: (Month/Day/Year)** Address: (including zip code)** Gender: Male Female Home Telephone Number: (including area code)** Work Telephone Number: (including area code ) Group Name/Number: (if available)** Social Security Number: (optional) Subscriber ID Number:** Health Insurance Carrier Personal Representative Information: Name: (First) (Middle Initial) (Last) Title (Sr., Jr., III) Personal Rep. Mother’s Maiden Name: (Required for verification purposes) Address: (including Zip Code) Telephone Number: (including Area Code) A copy of a Power of Attorney or other court-initiated document must be attached to this form in order for it to be processed. Attach supporting documentation and description (for example: Power of Attorney for health care decisions , Guardianship/Custodial, Executor of Estate) Type of Documentation: Signature/Date (The subscriber’s legal personal representative must sign and date this form for it to be processed.) Personal Rep. Signature : ___________________________________________ Date: ________________________ PLEASE KEEP A COPY OF THIS FORM AND THE INSTRUCTIONS FOR YOUR RECORDS ❏ The federal Privacy Rule, known as the HIPAA Priv acy Rule, requires your health plan to follow certain procedures before providing access to Pr otected Health Information (PHI) to someone other than the individual who is the subject of the PHI. PHI is information about an individual that can reasonably be used to identify the individual , and that relates to his/her past, present or future physical or mental health or condition, and t he provision of health care to the individual or the payments for that care. ❏ The health plan will release PHI to an individ ual’s Personal Representative upon written verification of such status. Acceptance of a Personal Representative will depend on the extent of their legal authority to make health-related decisions on behal f of the individual, such as whether they have Power of A ttorney or legal guardianship. ❏ The parent of a minor is generally considered to be the minor’s Personal Representative unless otherwise required by applic able law. If the parent is not co vered under the minor’s health plan, he/she will need to submit documentation to verify his/her parental status. ❏ The health plan will recognize as a Personal Repr esentative an executor, administrator, or a person recognized by law as having authority to act on behalf of a deceased individual or the individual’s estate. ❏ The health plan will not however, treat someone as an individual’s Personal Representative if we reasonably believe (1) the i ndividual may be subject to dom estic violence, abuse or neglect by the Personal Representative; (2) treating the person as a Personal Representative could endanger the individual; or (3) in the exercise of professional judgment (for example, in a licensed professional’s judgm ent), the health plan decides that it is not in the individual’s best interest to treat the person as a Personal Representative. ❏ A Personal Representative designati on will remain in effect until the individual, a court order, or an applicable law revokes it. ❏ To assist the health plan in responding to this request, please complete this form by printing or typing into the spaces provided. Attach additional pages if necessary to clarify your request. ❏ Mail or fax the completed form and supporting documentation to: _____________________________ _____________________________ _____________________________ Attn: Privacy Official Fax Number: ______________________________ ❏ If you h If you have any questions about this form, please call the Privacy Official at _______________________