Appointment Of Representative
If you need help with a grievance, coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act as your “representative.” This can be a friend, relative, your doctor, another provider or any other person you want to be your representative.
- If the item or service you are asking for is standardly covered by both Medicaid and Medicare, or just covered by Medicare, talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision or file a grievance or appeal on your behalf.
- To name someone besides your doctor to be your representative, call Member Services and ask for the Appointment of Representative form. You also can download and print a copy of the Appointment of Representative form from the Medicare website. You and your representative must sign the form. The completed and signed form will be valid for one year.
- If the item or service you are asking for is standardly covered by Medicaid only or if you are filing a grievance, you can also ask a friend or family member to act for you. You can name any person to act for you as your "representative." This person can ask for a coverage decision or file a grievance or appeal on your behalf. You must let us know in writing who your representative will be. The designation is valid for the coverage decision, appeal or grievance requested.
You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or other referral service. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you’ll need to fill out the Appointment of Representative form. You need to write to us to let us know your lawyer will represent you.
Remember, you don’t have to have a lawyer or a representative to ask for any kind of coverage decision, appeal or grievance.
Important: If your representative holds durable power of attorney or guardianship papers, you don’t need to fill out an Appointment of Representative form or send us anything else in writing.