Get Uha Authorized Representative Form 2020-2025

Filling out the UHA Authorized Representative Form online can streamline the process of designating someone to communicate with UHA on your behalf. This guide will walk you through each section of the form to ensure that you provide all necessary information accurately and clearly.

Follow the steps to complete the UHA Authorized Representative Form online.

1. Click the ‘Get Form’ button to obtain the UHA Authorized Representative Form and open it in your preferred editor.
2. Begin by entering the member's full name in the designated field for 'Member Name.' This is essential for identifying the individual authorizing the representative.
3. Provide the member’s phone number in the 'Phone Number' field to ensure direct contact if needed.
4. Fill out the member's address accurately in the 'Address' section, as this information is crucial for official correspondence.
5. Input the member’s unique member number in the 'Member Number' field to link the form to the correct account.
6. In the section for the authorized representative's details, enter their full name and address, including any additional contact information as required.
7. Specify the relationship to the member by filling in the 'Relationship to Member' field.
8. Check the box if you authorize UHA to disclose specific medical information related to HIV, substance use, or mental health, if applicable.
9. Articulate the reason for appointing the representative. Here, state that the purpose is for them to conduct an internal appeal review related to a prior determination made by UHA.
10. Document the date(s) of service associated with the appeal in the appropriate section.
11. Provide a brief description of the services relevant to the appeal to clarify the nature of the request.
12. Review the information and understand the right to revoke the authorization at any time by notifying UHA in writing.
13. Sign the form in the designated area and include the date of signing.
14. If signing as a personal representative, attach the required documentation, such as a Medical Power of Attorney, and include your phone number.
15. Once all fields are completed, save the changes to the form, and consider downloading or printing a copy for your records. You may also share it with relevant parties as needed.

Complete your documents online today to expedite the authorization process.