Appointment of Representative

You have the right to name a relative, friend, advocate, doctor, or someone else to act on your behalf. The person you name would be your Authorized Representative. If you want someone to act for you, then you and the person you want to act for you must sign and date a statement that gives this person legal permission to act as your Authorized Representative. This statement must be sent to us at:

Network Health Insurance Corporation
in care of Network Health Insurance Corporation
1570 Midway Place
PO Box 120
Menasha, WI 54952

Download the Appointment of Representative Form
(PDF format, Updated August 30, 2006)