Get Appointment Of Representative Form - Geisinger Health Plan

Filling out the Appointment of Representative Form for the Geisinger Health Plan online is a straightforward process that allows you to designate an individual to represent you regarding your Medicare claims. With this guide, you will receive clear and concise instructions to ensure that you complete the form correctly.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, fill in your name as the party seeking representation. Provide your Medicare or National Provider Identifier number, and appoint the individual by entering their name. This person will act on your behalf regarding your claims.
3. In Section 2, the appointed representative must complete their information. They need to write their name, accept the appointment, and confirm that they have not been disqualified from practice.
4. If applicable, in Section 3, the representative can choose to waive their fee for representation. They should sign and date this section once completed.
5. For Section 4, if the representative provided items or services to you, this section may be required. They should sign and date it to confirm they waive their right to collect payment from you regarding the items or services at issue.
6. After completing all sections, review the form for accuracy. You can then save your changes, download, print, or share the form as needed.

Begin filling out your Appointment of Representative Form online today to ensure proper representation.