Get Address Healthequity, A N Member Services

Completing the Address HealthEquity, A N Member Services form online is essential for allowing the release of protected health information. This guide will provide you with clear and comprehensive steps to ensure that your form is filled out accurately and efficiently.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the primary account holder's last name, first name, and middle initial (if applicable) in the designated fields.
3. Provide the street address, city, state, and ZIP code of the account holder in the respective sections.
4. Fill in the required email address and daytime phone number of the primary account holder.
5. Input the last four digits of the Social Security Number or HealthEquity ID Number in the specified field.
6. In the HIPAA Release section, check the appropriate box to indicate the purpose of authorization, such as 'At my request,' 'Family member assisting with health care,' or indicate 'Other' as needed.
7. If necessary, specify any limitations imposed on HealthEquity regarding this authorization in the space provided.
8. Note that this release remains effective until the closure of the applicable accounts unless revoked in writing.
9. Have the dependent sign and date the form, including their name, date of birth, and the date the authorization is effective until. If there is a personal representative involved, attach the necessary documentation.
10. Once all information is accurately filled out, save your changes, and proceed to download, print, or share the completed form as needed.

Complete your Address HealthEquity, A N Member Services form online today to ensure your health information is released appropriately.