Request Personal Representative
Fill out this form to request a personal representative. You can choose a personal representative to make health care decisions on your behalf. This person will have access to all of your personal health information. If you have questions, contact Member Services at 800-700-3874, ext. 5505.
Read the instructions on how to download and fill out a form.
Open Personal Representative Request Form
Contact Member Services
- Monday through Friday, from 8 a.m. to 5:30 p.m.
- Phone: 800-700-3874
- Deaf and Hard of Hearing Assistance
TTY: 800-735-2929 (Dial 711)
- Nurse Advice Line