CM-FRM-1019-001
Authorization to add an Advance Directive to
your GEHA Personal Health Records
A health care advance directive,
that includes a living
will
and/or medical power of attorney, lets
you share your wishes about your care with loved ones and health care providers
if
you become
incapacitated. A living
will
can convey thoughts about your values and what you consider quality of
life. Helpful information on preparing an advance directive can be found on line at the
American
Bar Asso
ciation.
If
you wish to add an advance directive document to your GEHA Personal
Health Records, please complete and submit the form below.
GEHA Personal Health Records (PHR)
help you keep track of your health data, such as
allergies, immunizations, medications, surgeries, health conditions and diseases. GEHA will
automatically update your Personal Health Records with your claims data. GEHA health plan
members can set up a secure PHR online when they register for a member web account at
geha.com
.
Authorization to add Advance Directive to GEHA Personal Health Records (PHR)
I
would like to add the attached Advance Directive to my personal health records (PHR). I understand
that I am responsible to keep this document up-to-date and ensure the version available on my
PHR is current.
Member ID:
First name: Middle initial:
Last name:
Date of birth:
Signature:
H
ere's how to have GEHA connect your advance directives to your personal health record:
1.
Sign in to your member web account at geha.com and establish a Personal Health Record (PHR).
2.
Download this Advanced Directive Authorization form from geha.com/ad
3.
Print and complete this form.
4.
Fax your advance directive and this authorization to 816.257.3255.
5.
You can also mail this completed authorization and your advance directive documents to:
GE
HA, P.O. Box 21542, Eagan, MN 55121
N
ote: Please only send copies. Your papers will not be returned to you. They will be copied into your
PHR, and the hard copies will be destroyed.
click to sign
signature
click to edit
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