Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in the editing interface.
2. Complete the member information in Part A. This includes entering your last name, first name, middle initial, address, city, state, email, home phone number, cell phone number, birth date, HMSA subscriber number, and ZIP code.
3. In Part B, select the type of request you are making: for a new authorized representative, an update to an existing request, or to revoke an existing request. Make sure to enter an effective date if you are revoking a representative.
4. For Part C, provide information about the authorized representative(s), including their names, relationships to you, and either their driver's license numbers or the last four digits of their social security numbers.
5. In Part D, consider if you want to limit the information that may be disclosed to the authorized representative(s). If you wish to place limitations, indicate your preferences by checking the appropriate boxes.
6. Decide on the expiration period for the appointment of authorized representative(s). You can select one year, three years, or specify a date that is less than five years.
7. Thoroughly read the rights detailed in Part E and ensure that you understand them. This section reviews your ability to revoke the appointment and other important notice information.
8. Sign and date the form in Part F. If someone other than you is signing the form, they must provide their name, indicate their relationship to you, and supply verification of their legal right to make this authorization.
9. Once all fields are completed, you can save your changes, download the form, print it, or share it as needed. Finally, submit your completed form to the HMSA Privacy Office.

Complete your document online today to ensure your authorized representative is set up correctly.