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Farm Bureau Health Plans


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How to Appoint a Representative

You can designate someone to act on your behalf.  This person is called your “authorized representative”.  Your authorized representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during certain situations, such as filing a grievance, an appeal, or requesting an exception.

To appoint an authorized representative, complete the Appointment of Representative form.  Both you and the person you have named as an authorized representative must sign the form.  Please mail the completed form to:  Farm Bureau Health Plans P. O. Box 240 Columbia TN 38402.  Please keep a copy of this form for your records.  

Please note that although we may retain the AOR form for overall member support as a best practice; the specific supplemental benefit providers (TruHearing, Delta Dental of Tennessee, VSP Vision Care, American Specialty Health - Silver&Fit, and Optum Rx) will require you to complete additional forms for their records. The easiest way to begin this process is by visiting our member portal which will easily link you to the benefit providers listed above.

Download an Appointment of Representative Form

If you do not wish to use the form upon your submission to Farm Bureau Health Plans, you may choose to submit a written request. Be sure to include the following:

  • Your name, address, phone number, and Medicare number
  • A statement appointing someone as your representative
  • The name, address, and phone number of your representative
  • The professional status of your representative (like a doctor) or their relationship to you
  • A statement authorizing the release of your personal and identifiable health information to your representative
  • A statement explaining why you’re being represented and to what extent
  • Your signature and the date you signed the request
  • Your representative's signature and the date they signed the request

If you are looking for the “Authorization for Release of Protected Health Information (PHI) form” then Click Here to be redirected to this form.