Get Representative Form

This guide provides clear instructions on how to complete the Representative Form online. Whether you are a UnitedHealthcare Community Plan member or their legal representative, this walkthrough will help you navigate the process effortlessly.

Follow the steps to fill out the Representative Form effectively.

1. Press the ‘Get Form’ button to acquire the Representative Form and open it in your online document editor.
2. Begin by filling out the top section of the form. This section requires the printed name of the member, their UnitedHealthcare Member ID number, and the date of birth.
3. Indicate the individual you wish to appoint as your representative by printing their name clearly in the designated area.
4. In the specified section, check off the permissions you are granting to your authorized representative. This may include discussions regarding health information, changes to your primary care provider, appeals, and form submissions.
5. Ensure that you or your legal representative signs the form in the signature area, and if applicable, print the name of the legal representative.
6. Provide your complete address, including city, state, and zip code, as well as your telephone number.
7. Record today’s date at the bottom of the form.
8. Finally, the form must be signed and notarized—ensure this is completed before submission.
9. Once completed, save your changes, download the document, print it, or share it as necessary.

Complete the Representative Form online today to ensure your representation needs are met.