Appointment of Representative Form for UHC

Appointment of Representative Form

For UnitedHealthcare Community Plan
You can choose to have a representative help you with your appeal or grievance.

This form allows you to name the person who will be your representative.

The top part of this form needs to be filled out by you. If you are not able to fill it out, your representative may fill it out for you.
Name*

First NameLast Name
Member Date of Birth*
Member ID#*
I,Patient Name, am appointing Friendly Dental Center to act on my behalf as my authorized representative for any appeals or grievances.
I understand and agree that:
- This authorization is voluntary;
- my health information may be disclosed to my authorized representative and may contain information created by other persons or entities including health care providers and may contain medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease and health care program information;
- I may revoke this authorization at any time by notifying UnitedHealthcare in writing; however, the revocation will not have an effect on any actions taken prior to the date my revocation is received and processed.
I also allow United Healthcare Community Plan to release and discuss my personal health information with the person named above, during my appeal.
Signature of Member*

Powered by Jotform SignClear
If person signing this authorization is not the member, describe relationship to the Member (i.e. Parent, Legal Representative)
Should be Empty: