Designating an Authorized Representative

The Authorized Representative Form allows you to appoint or revoke an individual or organization to act on your behalf. The individual or organization you indicate may contact HMSA and make requests regarding issues such as eligibility, billing, payment status, and claims on your behalf. They may also initiate appeals or complaints about your health coverage through HMSA.

You may limit the confidential member information that may be given to the authorized representative as listed on the form. If you leave that section blank, there will be no limitations on the information disclosed to the authorized representative.