Return to flip book view

OneDigital, Benemax, Inc 7 West Mill Street Medfield, MA 02052 Designation of Personal Representative _________________________________________________________ Date: ___________ Name (Last, first, middle initial) ________________________________________________ Employer/Plan Sponsor ________________________________ __________________ _____ ______________ Street Address City State ZIP Code __________________ ________________ ____________________________ Primary phone number Cell Phone E-mail Street Address I, _________________, trust and appoint _______________ to serve as my personal representative with regard to the [Name of Plan or Plans: ____________________ ] (collectively, the “Plan”). Relationship of my personal representative to me: _______________ Telephone number of my personal representative: _______________ Street Address of my personal representative: _______________ Date of birth of my personal (used for verification purposes on phone inquiries): _______________ Social Security number of my personal representative (used for verification purposes on phone inquiries): _______________ Password my personal representative must use to access protected health information about me: _______________ My personal representative has the power to serve as a personal representative as permitted under 45 CFR Sec. 164.502(g) and exercise all individual rights described in OneDigital Benemax’s Notice of Privacy Practices on my behalf. Print Name: _________________________ Signature: _________________________ Date: _________________________