Get Authorized Representative Form Sample

Filling out the Authorized Representative Form Sample online is a straightforward process designed to authorize another party to act on your behalf. This guide will walk you through each section of the form step by step to ensure that you provide all the necessary information accurately and efficiently.

Follow the steps to complete the Authorized Representative Form Sample online

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. In Part A, input your name and address, along with your daytime phone number, alternate phone number, medical record number, and Medicare number in the respective fields.
3. Move to Part B where you will authorize a designated person. Enter their name and address, including city, state, and ZIP code. Also, provide their daytime and evening phone numbers.
4. Check the box to grant permission for Kaiser Permanente Insurance Company to disclose your Protected Health Information relevant to your request. Specify the date of the request in the provided space.
5. In the specification section, check and initial to indicate the type of information you authorize for disclosure, such as medical records, drug/alcohol information, or psychiatric information. Sign and date accordingly.
6. If you wish to specify other health information to be disclosed, write the details in the provided area.
7. Decide on the effectiveness of the authorization. You can specify when this authorization should expire, either upon resolution of your request or on a particular date.
8. In the signature section, sign your name and date the form. If you are signing on behalf of someone else, complete Part C with the necessary authorizations.
9. Once all sections are completed, save your changes, download, print, or share the form as needed.

Complete your Authorized Representative Form Sample online today to ensure your rights and information are safeguarded.