If you decide to ask for a coverage decision or appeal a decision, either about your medical coverage (Part C) or your drug coverage (Part D), you can submit the request yourself or you can name another person to act for you as your “representative”.

There may be someone who is already legally authorized to act as your representative under State Law. If so, send us a copy of the form that names the person that can act on your behalf.

If you don’t have someone to act on your behalf you can choose a friend, relative, your doctor or other provider or other person to be your representative and complete an Appointment of Representative form. The form must be signed by you and by the person who you would like to act on your behalf. 

You may obtain a copy of the Appointment of Representative form by clicking on the link below:

Appointment of Representative Form

Complete the form making sure that both you and your representative sign the form. Print a copy for your records. Send a copy to the same location where you are sending (or have already sent) your appeal if you are filing an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial determination or decision.