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AUTHORIZED REPRESENTATIVE DESIGNATION FOR BENEFIT APPEAL
This form is for enrollees and dependents covered by the GEHA Health and Connection Dental Plus
®
plans.
Please place a check mark in front of each plan you want this Authorized Representative designation to be
applied. (NOTE: At least one line MUST be checked for this form to be valid.)
___ GEHA health plan (includes Connection Vision plan)
___ Connection Dental Plus
®
plan (includes Connection Vision plan)
Member name: GEHA ID number:
Patient name: Date of birth:
Designated Authorized Representative name:
(Referred to as the “Representative.” A contact person must be provided if this is an entity/organization.)
Representative complete address:
Representative phone number:
Claim number (if filed), Provider name, description of service, and date(s) of service (unless proposed):
I name the above person to act as my authorized representative in requesting information from GEHA regarding the
above-noted provider, service or proposed service.
The purpose is specifically for requests in regard to an adverse benefit determination and/or appeal only as outlined
in the Affordable Care Act (ACA).
IMPORTANT: Your signature below means that you understand and agree to the following:
• GEHA may disclose Protected Health Information (PHI) to the Representative, including, but not limited to
history, physical, physician notes, nurses’ notes, other treating providers, diagnosis, procedures, etc.
• The PHI disclosed to the Representative may include PHI you may consider to be sensitive information. (Please
note there is no limit to the information the Authorized Representative may request in regard to the provider and
name/dates of services documented above).
• If you sign this form, you may revoke the authorization at any time by notifying GEHA in writing at the address
below. Revoking this authorization will not have any effect on actions GEHA took before receiving the revocation.
• GEHA will not condition treatment, payment, enrollment or eligibility for benefits based on this form. Your
signature is required to process the request for appeal, plan information, and/or PHI initiated by the
Representative.
• Information disclosed as based on this form may be further disclosed by the Representative without your
authorization and may no longer be protected by federal or state privacy regulations.
• This authorization is only valid for the duration of the appeal and will expire when completed.
Please accept this appeal and any requests for PHI related to the appeal from my authorized representative on my
behalf.
Date:
Patient or Legal Representative’s signature:
Signer’s relationship to patient: Signer’s phone number:
(e.g., self, parent, legal guardian, power of attorney, etc.)
NOTE: If the signature is not that of the patient or the parent when the child is a minor, appropriate legal
documentation is required to accept the signature.
GEHA Appeals Department
P.O. Box 21542, Eagan, MN 55121
Fax 816.257.3256 \ Email GEHAappeals@geha.com
MAF0117
GE-FRM-1216-001
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signature
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