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Get Personal Representative Request - Bluecross Blueshield Of ...
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How to fill out the Personal Representative Request - BlueCross BlueShield Of ... online
This guide provides clear and supportive instructions for filling out the Personal Representative Request form for BlueCross BlueShield. By following these steps, you can easily designate someone to access your protected health information online.
Follow the steps to complete your request smoothly.
- Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
- In Section A, provide the Member's Information. Fill in your name, Member ID number, address, date of birth, optional social security number, phone number, and email address.
- In Section B, read the instructions carefully and enter the designated representative's information. Include their first name, middle initial, last name, address, city, state, zip code, phone number, date of birth, and relationship to you.
- Sign the form to confirm that you are requesting access for the individual named above. Also, provide the date of your signature.
- If the request is being completed by someone else on your behalf, they must fill in their name and relationship to you.
- Ensure that you retain a copy of this form for your records after completing it.
- Submit the completed form to BlueCross BlueShield of Tennessee, Privacy Office, at the provided address.
Complete your Personal Representative Request online today for convenient management of your health information.
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