Representatives include family members, friends, caregivers or providers. This is someone the member authorized to act on their behalf in writing. Or others legally able to act on behalf of the member, such as the member’s legal guardian or someone who holds power of attorney. If you haven’t already sent it, you’ll need to send us this proof of representation. You can send it using one of the methods at the bottom of this form.
3. Your information
Please provide your information in the following fields. All fields marked with an asterisk (*) are required.
