Get Khbe 79 Form

The Khbe 79 form is designed for individuals seeking to appoint an authorized representative for assistance with health coverage and related benefits. This guide provides clear instructions to ensure a smooth and straightforward completion of the form online.

Follow the steps to fill out the Khbe 79 form online effectively.

1. Use the 'Get Form' button to access the Khbe 79 form and open it in your preferred online editor.
2. Begin by entering your name at the top of the form. This identifies you as the applicant.
3. Input your date of birth accurately in the designated field to verify your age.
4. Select the type of request you are making by checking the corresponding box: 'Add New Representative', 'Change Duties of Current Representative', or 'Cancel Current Representative'.
5. Provide your authorized representative's full name, including the first name, middle initial, and last name in the respective fields.
6. Fill in the street/mailing address of your authorized representative, ensuring to include the city, state, and zip code.
7. Enter the primary phone number of your authorized representative, and if applicable, provide an alternative phone number.
8. Indicate your relationship to the authorized representative, and if applicable, include the name of their agency.
9. Check the activities you wish your authorized representative to assist you with, such as submitting applications and appealing decisions.
10. The authorized representative must sign the form to accept the appointment, followed by your signature as the applicant.
11. If someone other than the applicant signs the form, they must print their name and state their relationship, along with proof of legal authority.

Complete your Khbe 79 form online today to ensure your benefits are managed effectively.