Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to access and open the form in the online editor.
2. Begin by entering your member ID number in the required field. This number is essential for identifying your account.
3. Next, fill in your full name as it appears on your member ID.
4. Input your date of birth in the designated area. Make sure to follow the required date format.
5. Provide your current address, ensuring that it is complete and accurate.
6. If applicable, enter the address of the policyholder if it differs from your own.
7. List your contact phone number in case the UPMC team needs to reach you regarding the form.
8. Fill in the name of the personal representative you wish to designate.
9. Include the representative's phone number for communication purposes.
10. Provide the representative's address to complete their contact details.
11. If there are specific limitations on topics your representative can discuss, indicate this by marking ‘Yes’ or ‘No’ and provide details in the specified space.
12. If you would like to set an expiration date for this designation, specify that date in the provided area. If you prefer it to remain effective indefinitely, leave it blank.
13. Both the personal representative and the member must sign and date the form in the designated signature fields.
14. If the member is a minor or unable to sign, provide the name, relationship, and address of the signer in the appropriate fields.
15. Once you have completed all sections, save your changes. You may then download, print, or share the completed form as needed.

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