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Get Humana GN-97054-RR 2005-2024

Humana Inc. APPOINTMENT OF AUTHORIZED REPRESENTATIVE FORM Member Name Member ID Number I appoint Name of Member Name of Authorized Representative to act on behalf of in connection with any claim for coverage or benefits including receipt of any approvals or authorizations that are required before medical services. I authorize my representative to receive any and all information that is provided to me and to act for me and for my minor dependent if named above as the patient in providing any information to the group health plan that relates to any claim for coverage or benefits under this group health plan* Signature of Member Address Date Telephone Number hereby accept the above appointment. I am a/an Relationship to member Signature of Authorized Representative GN-97054-RR 01. 05 A0905 GF-1AOR. I authorize my representative to receive any and all information that is provided to me and to act for me and for my minor dependent if named above as the patient in providing any information to the group health plan that relates to any claim for coverage or benefits under this group health plan* Signature of Member Address Date Telephone Number hereby accept the above appointment. I am a/an Relationship to member Signature of Authorized Representative GN-97054-RR 01. 05 A0905 GF-1AOR. .

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