Help From a Caregiver
Do you have a son, daughter, other family member or caregiver who would like to help you with your health coverage selections?
We welcome their participation throughout the entire process, with your approval. You have the power to choose who, how long and what personal information can be discussed. We provide a Personal Information Authorization Form that gives us permission to speak with one or several people of your choice. Simply download, complete, and return the Personal Information Authorization Form to Mercer Marketplace 365.
Submitting this document authorizes us to provide assistance (for up to one year) without you physically being part of any conversation with a Benefits Counselor. We can discuss information about your insurance eligibility, plan enrollment, premiums and payment information, and personal health history or status. However, submitting this document does not allow us to enroll you in any health insurance plan without the appropriate Power of Attorney documentation on file. If you need to arrange for a Power of Attorney, please make your Benefits Counselor aware so they can provide the necessary information to you.
Personal Information Authorization Form
When you complete and email the form below, your caregiver will be able to assist you with many, but not all, of your health care insurance needs.
Click below to download and complete the worksheet. You will need to save a copy of it to your computer before you email it to us; your information will not be automatically saved, so if you close the form before saving your information, it will be lost and you will need to start again.