Authorized Representative Form – Fill Out and Use This PDF

This form provides permission for United HealthCare Services, Inc. (UHS), on behalf of itself and related companies, to discuss or give out your personal health information to a person who is your Authorized Representative. Your approval on this form limits the use of your information for that purpose only.

SECTION 1: Enrollee Information

By signing this form, I understand and agree that United HealthCare Services, Inc., on behalf of itself and related companies, may release my personal health information to _________________________________to

act as my Authorized Representative.

Please Note: This authorization does not allow your “Authorized Representative” to make any of your treatment decisions or direct care decisions. If you want help with your health care and treatment decisions, you must get additional legal documentation. If you have questions, contact your attorney.

SECTION 2: Authorized Use and/or Disclosure

To be completed by the Authorized Representative:

I, _____________________________________________________, hereby accept the above appointment.

I certify that I have not been disqualified, suspended, or prohibited from practice before the Department of Health and Human Services; that I am not, as a current or former employee of the United States, disqualified from acting as the beneficiary’s representative; and that I recognize that any fee may be subject to review and approval by the Secretary.

SECTION 3: Waiver of Fee for Presentation

Instructions: This form should be filled out if the representative waives a fee for such representation. (Note that providers or suppliers may not charge a fee for representation and thus, all providers or suppliers that furnished the items or services at issue must complete this section.)

I waive my right to charge and collect a fee for representing ______________________________________

before the Secretary of the Department of Health and Human Services.

SECTION 4: Waiver of Payment for Items or Services at Issue

Instructions: Providers or suppliers that furnished the items or services at issue must complete this section if the appeal involves a question of liability under section 1879(a)(2) of the Act. (Section 1879(a)(2) generally addresses whether a provider/supplier or beneficiary did not know, and could not reasonably be expected to know, that the items or services at issue would not be covered by Medicare.)

I waive my right to collect payment from the beneficiary for furnished items or services at issue involving Section 1879(a)(2) of the Act.

SECTION 5: Expiration and Revocation

I understand that I have the right to end this authorization at any time. I understand that, if I do not wish the person(s) named in Section 2 to remain my Authorized Representative, I must cancel this authorization. I understand that I must put this in writing and send this written notice of my decision to the health plans.

I understand that if UHS has already released any of my personal health information before UHS receives my written request to end this authorization, my notice cannot cancel out any action UHS has already taken.

CHARGING OF FEES FOR REPRESENTING BENEFICIARIES BEFORE THE

SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES

An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Department of Health and Human Services (DHHS) at the Administrative Law Judge (ALJ) or Medicare Appeals Council (MAC) level is required by law to obtain approval of the fee in accordance with 42 CFR §405.910(f). A claim that has been remanded by a court to the Secretary for further administrative proceedings is considered to be before the secretary after the remand by the court.

The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed by the representative and filed with DHHS. Where a representative has rendered services in a claim before DHHS, the regulations require that the amount of the fee to be charged, if any, for services performed before the Secretary of DHHS be specified. If any fee is to be charged for such services, a petition for approval of that amount must be submitted.

An approval of a fee is not required where the appellant is a provider or supplier or where the fee is for services

(1)rendered in an official capacity such as that of legal guardian, committee, or similar court appointed office and the court has approved the fee in question; (2) in representing the beneficiary before the federal district court of above, or (3) in representing the beneficiary in appeals below the ALJ level. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation.

AUTHORIZATION OF FEE

The requirement for the approval of fees ensures that representative will receive fair value for the services performed before DHHS on behalf of a claimant while at the same time giving a measure of security to the beneficiaries. In approving a requested fee, the ALJ or MAC considers the nature and type of services performed, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative.

CONFLICT OF INTEREST

Sections 203, 205 and 207 of Title XVIII of the United States Code make it a criminal offense for certain officers, employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from being representatives of beneficiaries before DHHS.

SAPDP3060880_XAUE000

S5820S5805S5921_PDP3060880_001 CMS 07/2008