CareLink Personal Representative Designation - Tufts Health Plan

Personal RepresentativeDesignationThis form allows members to notify Tufts Health Plan * of his or her Personal Representative. A personal Representative isa legally appointed individual to act on a Member’s behalf, for example a Healthcare Proxy or Durable Power of Attorney.Supporting legal documentation, such as a power-of-attorney or guardianship papers, must be submitted with this form. Therequest will not be granted until Tufts Health Plan reviews and approves the documentation submitted. Once granted, Tufts HealthPlan will treat the Personal Representative the same as the member with respect to accessing protected health information (PHI).The Member retains his or her right to act on his or her own behalf unless Tufts Health Plan receives legal documentation dictatingotherwise.MEMBER INFORMATION – (Please Print)Name of Member: __________________________________________________________ Date of Birth: ________________Member’s ID number: _____________________________________________________________________________________Member’s Phone Number:___________________________________________________________________________________Member’s Address: _______________________________________________________________________________________Subscriber Name (if different from Member): ___________________________________________________________________Subscriber’s Employer Name: _______________________________________________________________________________PERSONAL REPRESENTATIVE INFORMATION – (Please Print)Name of Personal Representative: _____________________________________________________________________Relationship to Member: ___________________________________________________________________________________Date of Birth of Personal Representative (Use 8-digit format: 11231949 for November 23, 1949): Type of Personal Representative (e.g. Durable Power of Attorney, Guardian)___________________________________________VERIFICATION QUESTIONS (In this section “You” and “Your” refers to the Personal Representative.)In certain circumstances, the answers you provide below will be used to verify your identity if you call for protected healthinformation about the Member. Note that these questions will be asked because the answers should be easy for you to remember,but you may enter other numbers as described below.• Please DO NOT provide anyone else with the answers to these questions.• You should keep a copy of this form for reference.Last 4 digits of your favorite credit card (you may use any four digit number):What is your mother’s date of birth*? (Use 8-digit format: 11231949 for November 23, 1949):*You may use any date, however, it cannot be a future date, and it must be a legitimate calendar date. For example, we cannot accept 11361949(November 36, 1949) because there are not 36 days in November. We also cannot accept 11232010 (November 23, 2010) because 2010 is a* For purposes of this request, Tufts Health Plan refers to Tufts Associated Health Maintenance Organization, Inc., Tufts Associated HealthPlans, Inc., Total Health Plan, Inc., Tufts Benefit Administrators, Inc., and Tufts Insurance Company. It also refers to entities acting on behalf ofTufts Health Plan.Tufts Health Plan Personal Representative Designation/CareLink Page 1 of 3

Personal RepresentativeDesignationfuture date.--Please Complete Form on Next Page—PLEASE READ THE FOLLOWING• If your request is granted, it will affect only communications from Tufts Health Plan and entities working on Tufts HealthPlan’s behalf, for example CIGNA HealthCare. If you also wish your employer, group health plan, physician or anyoneoutside of Tufts Health Plan to make this change, you must submit your request to them separately.• If the information on this form is not complete, Tufts Health Plan will return the form, and this request will not be considereduntil Tufts Health Plan receives complete information.• If either the Member or Group changes to a different type of health care benefits coverage provided by Tufts Health Plan,or the Member’s ID number or date of birth is changed, another form will need to be completed at that time.• You may change or revoke this request by sending a written request to Tufts Health Plan, Corporate ComplianceDepartment at the address below. You can obtain a Change/Revoke form by calling Tufts Health Plan Member Services atthe number on your ID card.SIGNATUREI have read and understand the above information. I acknowledge that by signing this form I have the legal authority toact on behalf of the Member as further detailed in the attached supporting legal documentation.Signature of Member (if competent) ________________________________________________________________________________________ Date: ______________________________ORSignature of Personal Representative _____________________________________________________________________________________ Date: ______________________________Please Return This Completed Form and Supporting Documentation To:Tufts Health Plan Personal Representative Designation/CareLink Page 2 of 3

Personal RepresentativeDesignationTufts Health Plan • Corporate Compliance Department •705 Mount Auburn Street • Watertown, MA 02472-1508Tufts Health Plan Personal Representative Designation/CareLink Page 3 of 3