IEHP AOR

IEHP: MEMBER AUTHORIZATION FORM
General Information
IEHPN/A
Case Manager Email*
example@example.com
Lake ElsinoreThe AnchorTemeculaChino HillsRialtoFontanaSan BernardinoThe HUBDHS OutreachColton
Form
I First Name Last Name appoint First Name Last Nameas my authorized appoint representative, to act on my behalf for the Inland Empire Health Plan (IEHP) services described below.
Member Information
1. Member Name - form*
2. Member ID or SSN
3. Member DOB
Authorized Representative Information
1. Authorized Representative Name*
2. Relationship To Member
3. Authorized Representative Address
4. Authorized Representative Daytime Phone Number
Request my Protected Health InformationChange my Primary Care PhysicianChange my assigned IPA or Medical GroupFile a Grievance or Appel (for Medi-Cal only)Change my Member demographic information (address, phone number, etc.)Other
Purpose & Member Rights:

By filling out this appointment, I agree to have my authorized representative to act on my behalf for the IEHP member services selected above.

IEHP and my authorized representative may only share the minimun necessary Protected Health Information (PHI) and other private facts to carry out IEHP services.

I understand that I do not have to sign this appointment and it is completely voluntary. My refusal will not affect my ability to obtain treatment, payment or eligibility for benefits. I understand that I have a right to receive a copy. I further understand that if the information provided by federal confidentiality law (HIPAA). However, California law does not allow the person receiving the health information by this Authorization to disclose it, unless a new Authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law.

I am aware that I may stop (revoke) this appointment at any time by sending a written request to IEHP at:

Inland Empire Health Plan | Attn: Member Services

P.O. Box 1800 | Rancho Cucamonga, CA 91729

Fax: 909-890-5877| Email: memberservices@iehp.org
The Appointment is effective immediately and will remain in effect for one year from the date of signature, or as indicated here:

MonthDayYear
Ending Date
AUTHORIZED REPRESENTATIVE ACCEPTANCE:

I have read this form and understand that:
- the IEHP Member may revoke this appointment at any time and appoint another individual(s) to act as their authorized representative;
- I have no other power to act on the Member's behalf, except for the IEHP services as stated above;
- I may not transfer or reassign my appointment.
I certify that:
- I have never been disqualified, suspended, or prohibited from practice before the Social Security Administration or the Department of Health and Human Services.
- I am not a current or former employee of the United States, disqualified from acting as the Member's authorized representative
By signing below I hereby accept this appointment:
Authorized Representative Signature*
Date of Signing*

MonthDayYear
Date
By signing below I hereby authorize this appointment:
Member Signature*
Should be Empty:

IEHP: MEMBER AUTHORIZATION FORM

General Information

Form