Designation of Authorized Representative

12409 W Indian School Rd Ste A108 Avondale, AZ 85392

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Designation of Authorized Representative
Insurance Plan Name
Member Name
Full Name
Member ID
Number
Date of Birth

MonthDayYear
Date
Member's Street Address

Street Address

Street Address Line 2

CityState

Zip Code
Designated Representative’s Address
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Provider of Service
Date(s) of Service/Proposed Service*
I,name * am appointing   First Name   Last Name   to act on my behalf as my authorized representative for (check all that apply)

a complaint
an appeall   documents from health plan regarding the above-noted service or proposed service.*
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 not be denied treatment, payment for health care services, or enrollment or eligibility for health care benefits if I do not sign this form;
- my health information may be subject to re-disclosure by the recipient, and if the recipient is not a health plan or health care provider, the information may no longer be protected by the federal privacy regulation;
- this authorization will expire one year from the date I sign the authorization. I may revoke this authorization at any time by notifying the health plan in writing; however, the revocation will not have an effect on any actions taken prior to the date my revocation is received and processed.
Patient’s signature Guardian/authorized representative’s signature
Date Signed*

MonthDayYear
Date
Signature of Member or Approved Party

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