Get This Form May Be Used To Notify Express Scripts Of A Personal Representative For The Individual

This guide provides clear, step-by-step instructions on how to complete the form that notifies Express Scripts of a personal representative for an individual. It aims to assist users in accurately filling out each section of the form online, ensuring that their representative is duly authorized to act on their behalf.

Follow the steps to effectively complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In Section I, 'Individual Identification', provide the individual’s name, gender, date of birth, member number, group identifier, address, and telephone number.
3. Proceed to Section II, 'Information About the Personal Representative', and fill in the representative's name, gender, date of birth, relationship to the individual, address, and telephone number.
4. In Section III, 'Individual’s Designation of Personal Representative', confirm the designation by signing and dating the section. Ensure to provide an expiration date for the designation, if desired.
5. If appropriate, complete Section IV, 'Personal Representative Notification of Status', by signing as the personal representative and entering the date. Ensure to attach any necessary legal documentation that supports this designation.
6. Review all provided information for accuracy. You may then save your changes, download the completed form, print it, or share it as required.

Complete your forms online today to ensure your personal representative is notified effectively.