How to submit your medical POA’s and other legal documents

What to expect

This form enables the upload of legal documentation appointing a person or organization as the Power of Attorney (POA), or similar designation, for health benefit related decisions. Only members or their personal representative should upload documents. This form should be completed in its entirety.

What's needed

Member's information

Most member information is located on the member identification (ID) card.

Subscriber / ID number

Group number (if available on ID card)

Date of birth

Possible legal documents

Legal, supportive documents for the medical POA should be readied for upload with these constraints in mind:

Individual document size cannot exceed 7 MB.

Only PDF files are supported at this time.

Power of attorney (health care, general, or durable)

Legal guardianship

Conservatorship

Executor of estate

Form Section

Form Section

Verify member's information

The following information is needed for member verification. All fields are mandatory unless marked (Optional).

Member's first name

Member's middle initial (Optional)

Member's last name

Member's date of birth

Date of Birth should not be more than Current Date.

Member's identification (ID) number

You will find your subscriber / identification number on your member card.

Providing your group number will help direct your form to the appropriate team.

Member’s group number

You may find your group number on your member card.

Upload supportive documents

You may submit up to 3 PDF files. Individual file size cannot exceed 7 MB.

Choose your PDF file(s).