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Fillable Printable OPM Form 1841

Fillable Printable OPM Form 1841

OPM Form 1841

OPM Form 1841

OPM Form 1841
January 2014
OMB Control Number 3206-0263
United States
Office of
Personnel Management
The Federal Government’s Human Resources Agency
Multi-State Plan Program
External Review Authorized Representative Form
An enrollee (or “patient”) of a Multi-State Plan may use this form to designate an authorized
representative to act on his or her behalf regarding the denial of service or payment by his or her health
insurance company. By completing and submitting this form, the patient acknowledges that the U.S.
Office of Personnel Management (OPM), which conducts external review under the Multi-State Plan
Program, will share information about the patient’s request for external review with the authorized
representative designated on this form.
Submit this completed form to OPM via email at MSPP@opm.gov,YLDID[DW or mail it to:
MSPP External Review
National Healthcare Operations
U.S. Office of Personnel Management
1900 E Street, NW
Washington, DC 20415
1. Patient information:
Patient Name Address, City, State, Zip Phone Email Patient’s
Member
Identification
Number
2. Plan information:
Primary Insured Name Insurance Company Plan Name Patient’s Relationship
to Primary Insured
3. Authorized Representative information:
Authorized
Representative Name
Address, City, State, Zip Phone Email Relationship to
Patient

2 OPM Form 1841
January 2014
_________________________________________________ _____________________
_________________________________________________ _____________________
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4. Patient statements (patient or patient’s legal representative, such as parent or legal guardian, to
initial each statement)
Patient’s
Initials
Statements
I authorize the above-named representative to:
with OPM on (enter date the request for external review was
or will be filed).
Represent my interests with regard to my external review case that was or will be filed
______________________
Deliver to and request and receive from OPM information regarding the above mentioned
external review case.
I understand that OPM and the MSP health insurance company will direct all information
regarding the case to the authorized representative, unless I provide specific written direction
otherwise.
I may revoke this permission at any time by submitting a request in writing to OPM at
mspp@opm.gov or at:
MSPP External Review
National Healthcare Operations
U.S. Office of Personnel Management
1900 E Street, NW
Washington, DC 20415
5. Authorized Representative statements:
Authorized
Representative’s
Initials
Statements
I certify that, to the best of my abilities, I will represent the best interests of the above-
named patient regarding the patient’s external review case.
I certify that there is no conflict of interest posed by any relationships I may have with the
health insurance company named above, any health care providers from whom the patient
is seeking care, or any other party interested in this case.
I certify that I will not transfer or assign this representation to another party.
Signature of Patien t or Patient’s Legal Representative Date
If signed by a patient’s legal representative, also submit a copy of legal authorization (for example: power of attorney,
guardianship papers, foster parent certification or court order).
Signature of A uth ori zed Representative not ed in item 3 above. Date
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3 OPM Form 1841
January 2014
Privacy Act Statement
In order for you to designate an individual to act on your behalf regarding a request for external
review, the U.S. Office of Personnel Management (OPM) requires you to submit this form.
Provision of information in the form is voluntary, but omitting any information may not allow
you to designate an authorized representative.
Routine uses of your records include the following:
Disclosure to agency contractors, such as Independent Review Organizations, for the
purpose of conducting external review;
Responses to congressional inquiries initiated by you;
Investigations of potential violations of law, and judicial or administrative proceedings to
which the Federal Government is a party (the information may be provided to another
agency, a court, an administrative body, or to the Department of Justice, when the
information is arguably relevant to the proceeding);
Investigations of data breaches and responses to data breaches;
Disclosure to the National Archives and Records Administration (NARA) or the General
Services Administration (GSA) for records management purposes;
Disclosure to program and policy staff within OPM for statistical and analytical studies
or to assist in formulating health program changes; and
Disclosure to researchers inside and outside of the Federal Government, approved in
advance by OPM on the basis of demonstrated aptitude and a written research plan,
conducting research on insurance trends and topical issues.
OPM has the authority to administer the Multi-State Plan Program under section 1334 of the
Affordable Care Act (42 U.S.C. 18054).
Public Burden Statement
We estimate this form takes an average of 5 minutes to complete, including the time for
reviewing instructions, getting the needed data, and reviewing the completed form. Send
comments regarding our estimate or any other aspect of this form, including suggestions for
reducing completion time, to the Office of Personnel Management, National Healthcare
Operations, 1900 E Street, NW, Washington, DC 20415-3430. The OMB Number 3206-0263
is valid. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.
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