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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.

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

2.   Personal Representative Information 

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

3. Electronic Signature

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