Additional Member Policies | Ascension Complete

Additional Forms

 

  •  PHI Revocation Form (PDF)
    • Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.
  • PHI Revocation Form (PDF)
    • Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.
  • Appointing a Representative
    • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
  • PHI Authorization Form (PDF)
    • Use this form when you want to allow Ascension Complete to share your health information with a person or group.
       
  • PHI Revocation Form (PDF)
    • Use this form when you want Ascension Complete to cancel or revoke your previous permission to share health information with a person or group.
  • Appointing a Representative
    • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
  • Disenrollment Form (PDF)
    • We don't want to see you go. Let us improve your experience with our plan. Please call Member Services. We are here to help. If you are still dissatisfied, please fill out and mail the disenrollment form.

If you have questions please, contact Member Services.