Designation of Authorized Representative Form - ERISA

This Designation of Authorized Representative form should be used to designate you as the authorized representative of the patient on ERISA types of employee sponsored health plans. For that reason you could use this form in conjunction with whatever assignment of benefits/lien form you already use (as developed by legal counsel in your state).

This form and your assignment/lien form should provide sufficient documentation for the ERISA plan administrator to allow you to pursue your patient’s ERISA rights. Although it states that the plan administrator is required to deal with the doctor as the patient’s designated representative, it does not incorporate the legal jargon that is found in many assignment/lien documents that are carefully drafted by legal experts in each state.

Note: This is a general form and additional information may be required depending on the specific health plan. Be aware of the requirements of the more prominent carriers in your state and modify this form in accordance with their standards.

 

File Size: 31 KB

File Type: .doc - Word document

File Name: Designation-of-Authorized-Rep-ERISA.doc