DESIGNATION OF PERSONAL REPRESENTATIVE (For Insurance Purposes)
I, ________________________________, (name) hereby designate the person named below to act as my personal representative and to represent my insured dependents, under the age of 18, who are listed below with __________________________________ Insurance company with full authority to act on my behalf and on behalf of the listed insured depends for all transaction with the company. For the purpose of this designation health information includes, but is not limited to, information pertaining to diagnosis, treatment, services planned and received, claims, benefit coverage and enrollment information. This designation of personal representative is voluntary and may be revoked at any time by calling or writing the company. Company is held harmless for any action that could arise from the use of health information released by company to my personal representative. ___________________________________ ________________________ Full name of personal representative (print) Title/Relationship ____________________________________________________________________ Mailing address (city, state, zip) ____________________________________ ___________________________ Daytime phone number Evening phone number Dependent(s) Name(s) and Date(s) of Birth ________________________________________________________________________ ______________________________ ______________________ ______________ Signature of insured Social Security number Date ________________________________________________________________________ Plan numbers (list each number that applies) I agree to act as the personal representative of the individual(s) and any dependant(s) listed above and acknowledge my responsibility in doing so. _________________________________ ___________ __________________ Personal representative signature Date Last 4 digits of the Representative SSN