Authorization of Personal Representative Form
Posted on January 28, 2015
You may need to see a loved one’s health information so that you can help with a claim or appeal. You may also need to have a loved one to see yours to help you. The law controls when HNE can give someone another person’s health information. In order to give HNE legal permission to share information, a member must fill out a form authorizing us to do so. Frequently, it is best to fill out the form before it is needed. That way, there will be no delays when you need us to share information.
Who can see a loved one’s health information without filling out a form?
A parent or legal guardian can see all information for a child under 12. If the child is 12 to 17, the parent or legal guardian can see everything except for information about pregnancy, abortion, HIV/AIDS, STDs, mental health, physical abuse, alcohol or drug use, and genetic testing. This is the law in Massachusetts.
Who might want to fill out a form allowing HNE to share health information with a loved one?
Anyone who might need a loved one to help with claims or appeals should give that person access to information. Here are a few examples:
o A child aged 12-17 may want a trusted adult to see information on the list of exceptions above.
o A college student or young adult may want to keep sharing information with parents after turning 18.
o An adult may want to share with a spouse or partner.
o An elderly person or a person with a disability may want to share information with a caregiver.
How does the Form work?
The form allows you to choose someone who will have access to your health information. It also allows you to choose what information will be shared with that person. You must sign the form to make it official.
Where do I find the form?
You can find it at this link:
http://www.healthnewengland.com/HNE_Members/documents/HNE_Authorization_of_Personal_Representative.pdf
Or follow these steps to find it online:
1. Go to HNE.com
2. Click “Members” on the left
3. Click “Forms” in the green bar above “Welcome Members”
4. Click on “Authorization of Personal Representative”, the first form on the page
How do I submit the form?
You can submit it via mail to:
Health New England, Attention: Enrollment Department, One Monarch Place, Suite 1500, Springfield, MA 01144-1500 or fax to 413.233.2635.
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