authorized personal representative form

Authorize a Personal Representative Request Form

This form can be used to initiate the process of becoming or appointing an authorized personal representative to manage third-party app access to a member's data.

Note: A signed Power of Attorney document is required for this access. After submitting this form, you will be asked to mail in a signed POA document. When we receive your POA, your request will be reviewed.

1. Geisinger Health Plan Member Information

Please enter all of the required information for the Geisinger Health Plan Member that is requesting to give authorization to their Personal Representative.

Required

First Name

Middle Initial

Last Name

Suffix

Street Address

Street Address 2

City

State

Zip

Date of Birth

Confirm Email

Phone Number

Member Number

2. Personal Representative Information

Please enter all of the required information below to identify the requested Personal Representative.

First Name

Middle Initial

Last Name

Suffix

Street Address

Street Address 2

City

State

Zip

Date of Birth

Confirm Email

Phone Number

3. Electronic Signature

You must enter your Electronic Signature below to submit this form.

Electronic Signature

Signature Date

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1. Geisinger Health Plan Member Information

2. Personal Representative Information

3. Electronic Signature