Form library
Managing your health
Managing your health care information
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you the right to access, amend, share and monitor your health info. The forms on the next page will help you manage that info.
Appointment of representative
A Medicare, Medicaid or dually funded Medicare and Medicaid member (or “patient”) may use this form to designate an authorized representative who can act on their behalf to file a grievance, request an initial determination or deal with appeal.
So we can authenticate the information, use the member’s name, date of birth, address and subscriber ID that matches our records. If faxing the form, also include this info on the cover sheet.
Submit the completed form to AOR Processing through fax or mail.
Fax to:
866-322-0051
Mail to:
AOR Processing,
PO Box 1495,
Shawnee Mission, KS 66222