Get Il Appointment Of Authorized Representative Form 2017-2024

If you are filing an appeal or grievance on behalf of a member, you need an Appointment of Representative (AOR) form or other appropriate legal documentation on file with Humana so that you are authorized to work with Humana on his or her behalf. Appointment of representative form - English.

A signed Appointment of Representative Form or an equivalent written notice must include the following: Medicare plan member's or enrollee's name. Medicare plan member's or enrollee's address. Medicare plan member's or enrollee's phone number. Medicare plan member's or enrollee's Health Insurance Claim Number (HICN)

An agent of record (AOR) is the individual health insurance agent you designate with your health insurance company to represent you and help you manage your insurance policy. Each individual policy you purchase has its own agent of record.

You may appoint a relative, friend, advocate, attorney, or your physician to act as your representative. A representative who is appointed by the court or who is active in ance with State law may also file an appeal or grievance for you.

Appointment of Authorized Representative Use this form to appoint an individual or organization as your Medi-Cal authorized representative. Your authorized representative may act for you on all duties related to your Medi-Cal eligibility and enrollment. Or, you may also limit duties.

The HIPAA Representative Form allows the patient to specify if access to all the records is being granted or if the patient wants to limit access to a specific health care incident(s).

Unless revoked, an appointment is valid for one year from the date that the AOR form is signed by both the member and representative.

Form CMS-1696 Approved. CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB No. 0938-0950. APPOINTMENT OF REPRESENTATIVE.