Get Ipp-po-01 Authorization To Appoint An Auth Represrev1-16 F

Filling out the IPP-PO-01 Authorization To Appoint An AUTH REPRESrev1-16 F is a straightforward process that enables you to authorize a representative to act on your behalf. This guide will provide step-by-step instructions to help you navigate each section of the form efficiently.

Follow the steps to complete the authorization form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Begin with Part A: Member Information. Fill in 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. Proceed to Part B: Request Type. Select one of the options: New Request, Update an Existing Request, or Revoke an Existing Request. Ensure to provide an effective date if revoking an existing request.
4. Move on to Part C: Information on Authorized Representative(s). Enter the name of each person or organization you are authorizing, their relationship to you, and either their driver's license number or the last four digits of their social security number.
5. In Part D: Appointment Limitations and Expiration, specify any limitations on the information that may be disclosed to the authorized representatives. If no limitations are needed, you may leave this section blank. Choose the expiration period for the appointment or provide a specific date.
6. In Part E: Your Individual Rights, read the explanations regarding your rights and the consequences of this appointment. Make sure you understand these before proceeding.
7. Finally, complete Part F: Signature. Print your name, sign, and input the date. If someone other than you is signing, provide their name, relationship to you, and include verification documentation of their authority to sign for you.
8. Review the entire form for completeness. Once all sections have been filled out properly, you can save changes, download, print, or share the completed form as required.

Complete and submit your form online today to designate your authorized representative efficiently.