Appointing a Representative
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 .
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 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 5 p.m.
FamilyCare Health Plans
2121 SW Broadway, Suite 300
Portland, Oregon 97201
