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How to complete your medical Power of Attorney (POA) Form

What to expect

This form allows a member to appoint a person or organization as their medical Power of Attorney (POA) for their health benefit-related decisions. Only members should complete this authorization form. 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 

  1. Form Section

Verify member's information

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

Date of Birth should not be more than Current Date.

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

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

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.