Get Appointment Of Personal Representative - Tufts Health Plan

The Appointment Of Personal Representative form allows you to designate someone to act on your behalf regarding your Tufts Health Plan coverage. This guide provides clear, detailed steps to assist you in completing the form online, ensuring that it is done accurately.

Follow the steps to fill out your form correctly

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the 'Member Name' field, enter your full name as it appears on your Tufts Health Plan insurance card.
3. Next, find the 'Member ID #' section. Input your unique member identification number, which can be found on your insurance documentation.
4. Fill in your address, including the 'Member Address,' 'City/State/Zip' fields. Ensure all details are accurate for communication purposes.
5. In the 'Member Date of Birth' field, provide your birthdate in the required format.
6. Enter your primary contact number in the 'Member Phone #' space to allow Tufts Health Plan to reach you easily.
7. Designate your Personal Representative by entering their name in the 'Name of Personal Representative' section.
8. Describe your relationship to the Personal Representative in the 'Relationship To Member' field.
9. Continue by providing the Personal Representative's address, phone, and email details in the corresponding fields.
10. If you wish to set an expiration date for this appointment, enter that date in the specified area. Otherwise, it will remain effective indefinitely.
11. When ready, review the document to confirm your understanding that you can revoke this appointment at any time in writing.
12. Sign in the 'Member Signature' field, ensuring that it is your own signature unless an authorized representative is completing the form on your behalf.
13. Print your name and date the form where indicated.
14. If someone other than yourself is signing, list their relationship to you and provide any documentation if required.
15. Finally, save your changes. You can download, print, or share the completed form as needed.

Complete your Appointment Of Personal Representative form online today to ensure your health care decisions are managed according to your preferences.