Additional Member Policies | Ascension Complete
Additional Forms
- Transition of Care Form
- 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 (PDF)
- Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
- Multi-language Interpreter Services (PDF)
- We have free interpreters to answer questions in multiple languages. Call Member Services.
- Scope of Appointment
- Member Reimbursement Claim Forms
- Transition of Care Form
- PHI Authorication Form - English (PDF)
- PHI Authorication Form - Spanish (PDF)
- Use this form when you want to allow Ascension Complete to share your health information with a person or group.
- PHI Revocation Form - English (PDF)
- PHI Revocation Form - Spanish (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.
- Multi-language Interpreter Services (PDF)
- We have free interpreters to answer questions in multiple languages. Call Member Services.
- Scope of Appointment Form
- Member Reimbursement Claim Form
- Transition of Care Form (PDF)
- 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.
- Multi-language Interpreter Services (PDF)
- We have free interpreters to answer questions in multiple languages. Call Member Services.
- Scope of Appointment Form
- Member Reimbursement Claim Form
Scope of Appointment
Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services.
- Use this form when you want to allow Ascension Complete to share your health information with a person or group.
- 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 (PDF)
- Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
Scope of Appointment
Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services.
- Use this form when you want to allow Ascension Complete to share your health information with a person or group.
- 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 (PDF)
- Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
- Transition of Care Form (PDF)
- Member Reimbursement Claim Form - English (PDF)
Member Reimbursement Claim Form - Spanish (PDF)
Scope of Appointment
Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services.
- Use this form when you want to allow Ascension Complete to share your health information with a person or group.
- 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 (PDF)
- Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
Member Reimbursement
Scope of Appointment
Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services
- Use this form when you want to allow Ascension Complete to share your health information with a person or group.
- 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 (PDF)
- Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
- Transition of Care Form
- Transition of Care Form - English (PDF)
- Transition of Care Form - Spanish (PDF)
- PHI Authorication Form - English (PDF)
- PHI Authorication Form - Spanish (PDF)
- Use this form when you want to allow Ascension Complete to share your health information with a person or group.
- PHI Revocation Form - English (PDF)
- PHI Revocation Form - Spanish (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.
- Multi-language Interpreter Services (PDF)
- We have free interpreters to answer questions in multiple languages. Call Member Services.
- Scope of Appointment Form
- Scope of Appointment Form - English (PDF)
- Scope of Appointment Form - Spanish (PDF)
- Member Reimbursement Claim Form
- Member Reimbursement Claim Form - English (PDF)
- Member Reimbursement Claim Form - Spanish (PDF)
If you have questions please, contact Member Services.