Appointment of a 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 for you as your “representative.” 

To give a friend, relative, your doctor or other provider, or other person the right to be your representative, Call member services at 1-866-600-2139 (TTY: 711) and ask for the Appointment of Representative form. You also can download and print a copy of the Appointment of Representative form. 

The form must be signed by you and by the person whom you would like to act on your behalf. The completed and signed form is valid for one (1) year.

If your representative holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.