Geisinger Gold enrollment

Authorized representative

As an authorized representative of the beneficiary you need to complete the following information.

Asterisk denotes a required field

Relationship to beneficiary

Spouse

Child

Grandchild

Brother / Sister

Other

First name

Last name

Phone number

Address line 1

Address line 2

City

State

Zip code

I certify that I have the legal authority to complete this form on behalf of the beneficiary and can provide proof of this authorization upon request.