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Get Meba Medical Plan Designation Of Authorized Representative For Claims & Appeals

Plan ( Plan ), you may name a representative to act on your behalf with respect to any aspect of your claim or appeal. If you would like to designate a representative, please complete this form and return it to the Plan Office. In order for the Plan to be able to disclose health information that is relevant to your claim and/or appeal to the representative designated below, in accordance with the privacy regulations issued under the Health Information Portability and Accountability Act of 1.

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