Personal Representative

{}

Web Content Viewer

PERSONAL REPRESENTATIVE APPLICATION

Become a Personal Representative

A Personal Representative has the legal authority to make health care decisions on a member's behalf.

Here are a few things to have ready when you apply:

Your represented member's ID card
Legal documentation, such as power of attorney, legal or court-ordered guardianship, birth or death certificates, or other supported documents.

Warning: It is a criminal offense to unlawfully access the information of others.

Need help?

Give us a call using the number listed on the back of your Member ID or contact us

You can find the paper version of the form on our Accessing and Sharing Your Account page.

PERSONAL REPRESENTATIVE APPLICATION

Tell us about the member you're representing

Fill in your member's details first, then we'll move to legal documentation.

View a sample card. Blue Cross ID Card

Member Account Details

ALL FIELDS REQUIRED

Subscriber ID

Group Number

Date of Birth (MM/DD/YYYY)

Oops! The system is currently unavailable. Please try again later.

GO BACK

PERSONAL REPRESENTATIVE APPLICATION

Tell us about the member you're representing

Fill in your member's details first, then we'll move to legal documentation. The first and last name must match to continue.

Member Contact Info

ALL FIELDS REQUIRED

First Name

Last Name

Email Address

Phone Number

Oops! The system is currently unavailable. Please try again later.

GO BACK

PERSONAL REPRESENTATIVE APPLICATION

Tell us about the member you're representing

Fill in your member's details first, then we'll move to legal documentation.

Member Mailing Address

Street Address 1

Street Address 2 (optional)

City

State

Zip Code

Oops! The system is currently unavailable. Please try again later.

GO BACK

PERSONAL REPRESENTATIVE APPLICATION

Provide Documentation

Submit up to five clear pictures of legal documents stating you should be allowed to access their account as their representative.

Supported Documents include...

Power Of Attorney
Legal Guardianship
Court-Ordered Guardianship
Birth or Death Certificate
Other Supporting Documents

Upload A Document

AT LEAST ONE DOCUMENT IS REQUIRED

Select Document Type

Accepted file formats include jpeg, png, pdf, doc, and docx. Max 5MB each.

Oops! The system is currently unavailable. Please try again later.

GO BACK

PERSONAL REPRESENTATIVE APPLICATION

Now we need some information about you.

Fill in these fields about yourself. If you're a BlueCross member, make sure we get your Subscriber ID.

Your Contact Info

First Name

Last Name

Your Subscriber ID (optional)

▼

Date of Birth

Marital Status

Gender

Oops! The system is currently unavailable. Please try again later.

GO BACK

PERSONAL REPRESENTATIVE APPLICATION

Now, we need some information about you.

Your Mailing Address

ALL FIELDS REQUIRED

Street Address 1

Street Address 2 (optional)

City

State

Zip Code

Oops! The system is currently unavailable. Please try again later.

GO BACK

PERSONAL REPRESENTATIVE APPLICATION

Now, we need some information about you.

Please provide your contact information.

Your Contact Info

ALL FIELDS REQUIRED

Email Address

Confirm Email Address

Phone Number

Relationship to Member

I have read, understand and agree to the Terms of Use and Privacy Policy

Oops! The system is currently unavailable. Please try again later.

GO BACK

PERSONAL REPRESENTATIVE APPLICATION

Last step! Confirm your email

Enter the security code to complete your application.
We've sent a code to:

example@abc.com

Be sure to check your spam or junk folders. The email expires in 24 hours.

Enter Security Code

Resend Code

Success! We've sent a new code to your email address

Oops! The system is currently unavailable. Please try again later.

Need help?

Give us a call using the number listed on the back of your Member ID or contact us

PERSONAL REPRESENTATIVE APPLICATION

Please double check the name you entered.

This doesn't match what we have in our records for the name of the member. Please check the spelling, ensuring that you're using a first and last name that matches legal documentation, and try again.

ALL FIELDS REQUIRED

First Name

Last Name

Oops! The system is currently unavailable. Please try again later.

Need help?

Give us a call using the number listed on the back of your Member ID or contact us

PERSONAL REPRESENTATIVE APPLICATION

We Got Your Submission

Please give us 10 business days to review your request. Once approved, you can register an online account.

When your request has been approved or denied, we’ll send an email to:

Reference Number:

Need help?

Give us a call using the number listed on the back of your Member ID or contact us

Web Content Viewer

Warning: It is a criminal offense to access the information of others.