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.
  • 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 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.

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.

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.

Scope of Appointment

Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services.

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.

Scope of Appointment

Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services.

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.
Member Reimbursement

Scope of Appointment

Multi-language Interpreter Services (PDF) - We have free interpreters to answer questions in multiple languages. Call Member Services

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.
  • 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.