Authorization of Personal Representative Form
Posted on September 15, 2017
A personal representative is someone who is authorized to contact Health New England and discuss your personal health information on your behalf. This person can be a family member, friend, caregiver or anyone you trust to speak on your behalf. If you would like to name a personal representative, you can fill out the Authorization of Personal Representative form and return it to us. The form can be found on our website at healthnewengland.org/medicare/home/Forms.
If you want your Personal Representative to file prior approval requests, claims, grievances or appeals on your behalf, your Personal Representative MUST complete Section 8 on the form and accept the appointment. Authorization to do these things is only valid for ONE YEAR from the date you sign the Authorization Form.
You may revoke an authorization or end an appointment at any time by sending a letter to Health New England – Medicare Advantage Plan, Enrollment Department, One Monarch Place, Suite 1500, Springfield, MA 01144-1500. Please include your name, address, member identification number and a telephone number where we can reach you.
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