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The instructions walk through entering member identification details, specifying recipients, selecting the scope of information to release (all, limited, and sensitive categories), stating the approval purpose, and choosing an expiration date that cannot exceed one year. It also covers required review steps, signature matching, and rules for signing as a designated legal representative with supporting legal documentation (rev. 08/24).",{"@graph":63,"@context":123},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/member-authorization-form-instructions-for-completing/283868/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/member-authorization-form-instructions-for-completing/283868.png","ImageObject",442,249,{"name":88,"@type":89},"Gelato","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115,119],{"name":106,"@type":107,"acceptedAnswer":108},"Who can this authorization apply to, and what does Part A require?","Question",{"text":109,"@type":110},"This authorization applies when a member requests release of health information to another person or company. Part A requires the member’s name, date of birth in MMDDYYYY format, full address, phone numbers, identification number, and group number if applicable.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the form specify who will receive the member’s information?",{"text":114,"@type":110},"Part B requires the full name of the specific person or company you want to receive the information. If you select “Other,” you must provide first and last name (if available), company name (if applicable), and how they relate to you.",{"name":116,"@type":107,"acceptedAnswer":117},"What information can be released and how is sensitive information handled?",{"text":118,"@type":110},"Part C allows the member to select either all information or limited information by checking the relevant boxes. For sensitive or personal topics, additional approval is required by checking the applicable box(es).",{"name":120,"@type":107,"acceptedAnswer":121},"When does the approval expire, and what signing rules apply?",{"text":122,"@type":110},"Part E lets the member choose a standard one-year end date or an earlier “other” date; authorization cannot be granted for more than one year. Part F requires signing and dating, with the name/signature matching Part A; designated legal representatives must complete the designated legal representative/guardian section and include supporting legal documents.","https://schema.org",{"og:url":78,"og:type":125,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":127,"canonical":78},"index,follow",{"doc_id":129,"site_id":56},283868,1790556616,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":88,"user_avatar":134,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":144,"read_time":73},19241457091524,"https://us-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Instructions for completing the Member Authorization Form  \nIf you have any questions, please feel free to call us at the customer service number on your member identification card.  \nPlease read the following for help completing page one of the form.  \nPart A: Member information  \nThis section applies to the member who is asking for the release of his or her information to another person or company.  \n❶ Print your last name, first name, and middle initial.  \n❷ Write your date of birth in this format: mmddyyyy. (If you were born on October 5, 1960, you would write 10051960. )  \n❸ Write your full street address, city, state, and ZIP code.  \n❹ Write your daytime phone number (including area code.)  \n❺ Write your cell/mobile number (including area code.)  \n❻ Identification number  \nYou will find this number on your member identification card.  \n❼ Group number  \nYou will find this number on your member identification card. If your identification card does not have a group number leave this blank.  \nPart B: Person or company who will  \nreceive this information  \n❽ Write the full name of the person or company that you want us to give your information to. Please don't use a general term like “my daughter” or “my son” as it will not be accepted. You need to be specific.  \n❾ If you check “Other,” give the first and last name (if available), the name of the company (if applicable), and how they relate to you.  \nPart C: Information that can be released  \nThis section tells us what information you would like us to release: all or just some.  \n❿ For “all of your information,” check the first box.  \n⓫ For “limited information,” check the second box and the boxes that apply to you.  \n⓬ Some topics may be very personal or sensitive to you. If you wish to approve the release of this type of information, check the box(es) that apply to you.  \nRev. 08/24  \nPlease read the following for help completing page two of the form.  \nPart D: Purpose of this approval  \nThis section tells us the reason you’ve asked for the release of your information.  \n❶ Check the first box to let us know to give out this information as shown on this form.  \n❷ Check the second box for a specific reason. An example might be to settle a life insurance claim.  \nPart E: Date your approval expires  \nYou have two choices of when you would like this approval to end.  \n❸ Check the first box for the standard one year that it will end.  \n❹ Check the second box for an earlier date (Other than one year), and give the date you wish this approval to end.  \nYour authorization/approval can’t be granted for more than one year.  \nPart F: Review and approval  \n❺ Sign your name and put the date on the form. Your name and signature must match the information in Part A.  \n❻ If you are signing this form on behalf of another person, or if you have Power of Attorney for health care, or are a legal guardian/conservator you must do the following:  \n❶  \n❷  \n❸❹  \n❺  \n❻  \n• You must complete the Designated Legal Representative/Guardian section.  \n• You must also provide us with a copy of the legal document showing that you are approved and include it with this form.  \nExamples of legal documents:  \n• Health Care, General or Durable Power of Attorney. This document gives someone you trust the legal power to act on your behalf and make health care decisions for you.  \n• Legal Guardianship. This is when the court appoints someone to care for another person.  \n• Conservatorship. This happens when a judge appoints a responsible person to make decisions for someone who can’t make responsible decisions for him/herself.  \n• Executor of estate. This type of document would be used when the person who is being represented has died.  \nInstructions for completing the Member Authorization Form  \nSi necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número deservicio al cliente que aparece al dorso de su tarjeta de identificación o en el folleto de inscripción.","cbCaivptZc1ZVUIz","https://ap.wps.com/l/cbCaivptZc1ZVUIz","pdf",706930,"English","# Part A: Member information\n## Part B: Person or company who will receive this information\n## Part C: Information that can be released\n## Part D: Purpose of this approval\n## Part E: Date your approval expires\n## Part F: Review and approval","[{\"question\":\"Who can this authorization apply to, and what does Part A require?\",\"answer\":\"This authorization applies when a member requests release of health information to another person or company. Part A requires the member’s name, date of birth in MMDDYYYY format, full address, phone numbers, identification number, and group number if applicable.\"},{\"question\":\"How does the form specify who will receive the member’s information?\",\"answer\":\"Part B requires the full name of the specific person or company you want to receive the information. If you select “Other,” you must provide first and last name (if available), company name (if applicable), and how they relate to you.\"},{\"question\":\"What information can be released and how is sensitive information handled?\",\"answer\":\"Part C allows the member to select either all information or limited information by checking the relevant boxes. For sensitive or personal topics, additional approval is required by checking the applicable box(es).\"},{\"question\":\"When does the approval expire, and what signing rules apply?\",\"answer\":\"Part E lets the member choose a standard one-year end date or an earlier “other” date; authorization cannot be granted for more than one year. Part F requires signing and dating, with the name/signature matching Part A; designated legal representatives must complete the designated legal representative/guardian section and include supporting legal documents.\"}]","Member Authorization Form - Instructions for Completing | PDF",1789621096]