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Form 391 C - Designation Of An Authorized Representative Form - Highmark Blue Shield - Pennsylvania Page 3

Complete for Act 68 grievances only when provider is acting on member's behalf:

Health Care Provider Number: _______________________

I understand that if my health care provider files a grievance on my behalf, I cannot file a grievance for the same

issue unless I rescind my consent in writing. I have the right to rescind my consent in writing at any time during

the grievance process. In the event that my health care provider fails to file or pursue a grievance through the

second level grievance process, this consent shall be deemed as having been automatically rescinded without

further action on my part.

Once a health care provider assumes responsibility for filing a grievance, the health care provider may not bill

the enrollee or the enrollee's legal representative for services provided that are the subject of the grievance until

the external grievance review has been completed or the enrollee or the enrollee's legal representative rescinds

consent for the health care provider to pursue the grievance.

If the health care provider elects to appeal an adverse decision of a CRE (Certified Review Entity), the health

care provider may not bill the enrollee's legal representative for services provided that are the subject of the

grievance until the health care provider chooses not to appeal an adverse decision to a court of competent

jurisdiction.

I have read, or have been read this consent form, and have had it explained to my satisfaction. I understand

the information in the consent form.

Member or Member's Legal Representative:

(If member is a minor or legally incompetent)

Signature

Date

Relationship to member

Address

Witness:

Signature

Date

Note: A health care provider may not require member/member's legal representative to sign a document

authorizing the health care provider to file a grievance as a condition of providing a health care service.

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Form 391 C - Designation Of An Authorized Representative Form - Highmark Blue Shield - Pennsylvania Page 3