Authorize a Personal Representative Request Form
Starting in August 2021, 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. Any prior submissions of this form will be reviewed beginning in August 2021.
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 received your request will be reviewed.