You can use this form to manage the protected health information of someone who’s passed away.

What you’ll need:

  • The subscriber ID card, also known as enrollee ID card
  • A copy of the death certificate of the deceased person
  • A printer to print the form
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.

If you have any questions, please contact us.

Affidavit of Next of Kin (PDF)