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For a member Representative to request that FamilyCare Health Plans release Personal Health Information to someone other than our Member or if a member wants to appoint a representative to work with us to help them with their Healthcare decisions, we need to have the member complete our Confidential Communication Request form (coming soon).

Along with the signed form, we need for the member representative to submit legal documentation that you are the member ’s Authorized Representative.

Approved documentations must be one of the following;

• A court-appointed legal guardian with authority to make health care decisions -attach a copy of guardianship papers
• A person who has a Health Care Representative - attach a copy
• A person designated in a written advance directive - attach a copy, or A person authorized by state law to sign (spouse, parent, family member, or

This protects you, and our member, by allowing only an legally Authorized Representative and our member to request a release of confidential information to another party or location.

You will need to complete this Confidential Communication Request form (coming soon) and return to us with legal documentation of your Authorized Representative status before we can release member information. Once we receive this completed request form, we will keep it on file and update our records reflecting this change.

Again, thank you for selecting FamilyCare Health Plans as your health care partner. If you have any questions or need additional information, please call our Customer Service Department toll free at:
866-798-2273 or TTY 800-735-2900, Monday through Friday from 8 a.m. to 8 p.m.