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_____ name of person granting authorization and relationship to service benefit plan member (if other. Web you may designate a personal representative who will act on your behalf in making decisions related to health care,.
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Web blue cross may request information, now or in the future, as it deems necessary to confirm authorized representative status. Web designation of authorized representative and release of information form i, (print your name), name.
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Please include as much information as you can. Web an authorized representative is not, however, a person who has legal authority to act on behalf of a member. Web an authorized representative is not, however,.
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Web you may designate a personal representative who will act on your behalf in making decisions related to health care, which includes treatment and payment issues. If you are consenting to permit your health care.
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