Personal Representative Request Form

State:
Multi-State
Control #:
US-3578
Format:
PDF
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Description

This form is used by a health plan to identify a representative of a subscriber who has legal authority to make health care decisions for the subscriber, such as a guardian, person appointed in a power of attorney, or other documented authority.
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FAQ

DESIGNATION OF AN AUTHORIZED REPRESENTATIVE (DOR) (Failure to complete this form in its entirety will invalidate this authorization) An Authorized Representative is a person you authorize to act on your behalf, in pursuing a claim or an appeal of a denied claim.

A legal personal representative can be appointed by the probate of the will of the deceased, letters of administration of the estate of the deceased, or any other similar grant. You will need to provide evidence of your appointment when you are added to ASIC's register.

A personal representative is appointed by a judge to oversee the administration of a probate estate.When a personal representative is nominated to the position in a will, he's commonly called the executor of the estate.

You can do this by simply signing your name and putting your title of executor of the estate afterward. One example of an acceptable signature would be Signed by Jane Doe, Executor of the Estate of John Doe, Deceased. Of course, many institutions may not simply take your word that you are the executor of the estate.

A personal representative or legal personal representative is the executor or administrator for the estate of a deceased person.In this case, a personal representative has power of attorney, a legal document that allows the representative to act for the other person when making legal or financial decisions.

This form identifies a person who has legal authority to act on a member's behalf in making decisions. related to the member's health care.

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Personal Representative Request Form