Get Personal Representative Request - Cigna

This guide will help you navigate the process of completing the Personal Representative Request form from Cigna. Whether you are appointing someone to manage your health benefits or sharing your protected health information, this document is essential for ensuring that the right person has the authority to act on your behalf.

Follow the steps to complete the form accurately and effectively.

1. Press the ‘Get Form’ button to access the Personal Representative Request form and open it in your preferred online editor.
2. Begin by providing your personal identification information. This section requires your name, date of birth, phone number (required), and optional information such as your social security number and customer ID card number.
3. If applicable, provide information about your secondary coverage, including other employer name and group or account number. Indicate whether this request applies to all coverage by checking ‘Yes’ or ‘No’.
4. Identify the personal representative by filling in their name, relationship to you, date of birth (in the correct format), and their preferred address for communications.
5. State the reason for this request in the designated space provided.
6. Complete the verification questions for the personal representative, including creating a 4-digit PIN and providing your mother’s date of birth (in the specified format).
7. Review the important notes regarding the accuracy of the information provided on this form. Incomplete forms will be returned to you for correction.
8. If you are appointing a personal representative legally, complete section A by signing and dating the form.
9. If designating someone as your representative, have the customer (you) sign in section B and ensure this signature is notarized.
10. If applicable, if the request is made for a minor, indicate the age of the minor and be prepared to provide additional information.
11. Return the completed form to CareAllies via mail or fax as specified at the end of the document. You can save the form changes, download, print, or share it as needed.

Complete your Personal Representative Request online today for seamless health benefit management.