Who Can Speak for Me?

To appoint a representative:

1. Fill out the Appointment of Representative Form in your preferred language

2. Print the form
3. Sign the form
4. Have your appointed representative sign the form
5. Mail the form to the Health Plan of San Mateo

Durable Power of Attorney

This gives someone you chose the power to make decisions about your medical care in the event that you become too sick to make them yourself. HPSM recommends that everyone appoint durable power of attorney to someone they trust. To do that, fill out Part 1 of the Advanced Health Care Directive, have it notarized and follow the instructions on the last page.

Authorized Representative

If you are unable to make decisions on your own behalf because of your medical condition, you (or a legal entity) may appoint a representative to do that. This person has all the powers listed above under “Appointment of Representative” above, but they can also make decisions about your medical care. To authorize a representative, fill out Part 2 of the Advanced Health Care Directive form, have it notarized and follow the instructions on the last page.

Protecting Your Privacy

If someone contacts HPSM claiming to be your representative, we will check our records to confirm their status before sharing your health information or taking any action.