(the "Plan") and its representatives are, in most cases, prohibited by federal law from discussing your health information with anyone, including your spouse, your parent, or your child, other than you. If you would like for the Plan or representatives or agents of the plans to be able to discuss your health information, including claims and payment information, with someone other than you, to resolve any issues involving treatment or payment of claims under your health plan, you MUST complete this form to appoint a Personal Representative. This form does not give your Personal Representative any legal rights beyond those listed below.