2024 Plan Documents

We are committed to ensuring your health information is safe, while giving you the flexibility to have a family member, friend or loved one – your “representative” – help make decisions on your behalf. State and federal law requires different forms to be used depending on the actions you want your representative to take on your behalf. We’ve outlined the purpose of each of these forms below.

Authorization for Use or Disclosure of Health Information.
Completing the Authorization for Use or Disclosure of Health Information form will allow your designated representative to call Member Services to ask medical questions. This form is valid for as long as you are an Aspire Health Plan member.

USE FOR: Medical benefit questions, claims, and bills.

Authorization for Use or Disclosure of Health Information (PDF):  English | Español

• This form doesn’t override a Power of Attorney (POA). Don’t complete this form if you have a valid POA.
• You need to complete a separate form, if you need help filing an initial request for coverage, a grievance or appeal.
• This form is valid as long as you are a health plan member
• You have the right to revoke this document at any time

Appointment of Representative form.
Completing the Appointment of Representative allows your designated representative to call our Pharmacy Benefits Manager, MedImpact, to ask questions about your Part D prescription drug benefits, claims, or bills. For your Part C benefits, the form also allows the authorized representative to file an appeal or grievance for you, or make an initial coverage request. You will need to renew this form each year.

USE FOR: Part C appeals, grievances, and coverage decisions, as well as Part D prescription drug benefits, claims, bills, appeals, or grievances.

Appointment of Representative Information Form Instructions (PDF):  English | Español

Appointment of Representative Information Form (PDF): English | Español

• This form only allows your representative to assist you with initial coverage requests, grievances or appeals.
• Your doctor can make a coverage request and file certain appeals without being your representative.
• This form is only valid for one year.
• The form should be signed by both you and the individual you would like to represent you.
• Once you have completed the form, you must submit that form via fax for mail to the applicable fax number or address listed above before we can talk to your representative.
• You have the right to revoke this document at any time

Already have a Power of Attorney (POA)? Make sure it’s Valid
A valid POA must:

• Name your agent and your relationship to the agent
• State when it becomes effective (e.g., “immediate”) and how long it lasts
• Include the right to revoke at any time
• Be properly signed AND notarized or witnessed