WebHumana Grievance and Appeal Department APPOINTMENT OF AUTHORIZED REPRESENTATIVE FORM. GF-01_AOR GCA04KFHH 3/19. Member Name Member ID … WebAppointment of Representative Form. You also can get the Appointment of Representative form on the Centers for Medicare & Medicaid Services Website.

Members Documents and Forms Author by Humana

WebAppointment of Representative Form Appointment of Representative Form Member Name Member ID Number Member Date of Birth Reference Number Medicare ID … Webrepresentative to receive any and all information related to this case that is provided to me, and to act for me and for my minor dependent, if named above, in providing any … hobbit ps4 game

Form Central - Humana home

WebInstructions for completing this form: 1. You must insert the name of the person (your spouse or legal guardian, your physician or the facility [hospital, ambulatory surgery … WebFind out most commonly used forms via our Humana website below: Commercial Health Benefits Claims Form. Commercial Pharmacy Claims Form. Grievance and Appeals … WebSend third party liability form to: TRICARE East Region Attn: Third party liability PO Box 8968 Madison, WI 53708-8968 Fax: (608) 221-7539 Subrogation/Lien cases involving third party liability should be sent to: Humana Military PO Box 740062 Louisville, KY 40201-7462 Fax: (800) 439-7482 Email: [email protected] Enrollment hrt protects against