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Managing your health

Managing Your Healthcare Information - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to get it, change it, share it and monitor it. The forms on the following page will help you manage your healthcare information.

Appointment of Representative - A Medicare, Medicaid or dually funded Medicare and Medicaid member (or “patient”) may use this form to designate an authorized representative to act on his or her behalf in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeals process. Be sure to include the member’s name, date of birth, address information and subscriber ID that we have within our systems. This information is required for identification and authentication purposes. This information can be added on a cover sheet if you are unable to legibly add on this form.

Submit this completed form to AOR Processing via:

Fax to:

866-322-0051

Mail to:

ATTN: AOR PROCESSING
PO BOX 1495
Shawnee Mission, KS 66222