Authorized Rep Form

This form lets you choose who can see your personal information.

Who the member says can see their information.

Please Note: The member listed below must sign this form.

I let this person see my information.
Member information not found

How this works: This person listed above can help and act for you. They can help you with your claims and medical records. They can also help you with other information that may include medical records for:

  • Alcoholism
  • Substance Abuse
  • Mental Health
  • Prescriptions
  • HIV Status
  • HIV Test Results

You must check one or more of the boxes below so the person can act on your behalf.
This designation shall remain valid for the length of time selected below.

You will allow us to give this person your information until you tell us to stop.

You can write to us at:

You understand that we (Magellan Health) are not responsible for how information is used by the person. We will not give any information after you tell us to stop.

This is a copy and can be used as the original.

Type your name. This is your electronic signature.