Appointment of Representative
You may appoint a relative, friend, advocate, attorney or your physician to act as your representative. A representative who is appointed by the court or who is active in accordance with State law may also file an appeal or grievance for you. For incapacitated or legally incompetent enrollees where there are appropriate legal papers or other legal authority, such supporting documentation may be submitted as evidence of representation.
Below you will find the form you need to download and fill-out to complete your representative appointment.
- Download the Appointment of Representative Form
How to Complete the Representative Form
Please print or type. At the top, fill in your full name and Medicare number. If you appoint more than one person, you may want to complete a separate form for each.
Section 1: Appointment of Representative
Give the name and address of the person(s) you are appointing. You may appoint a relative, friend, advocate, attorney or your physician or any other qualified person to represent you. In addition, you must date and sign this section as the beneficiary, and provide your address and phone number.
Section 2: Acceptance of Appointment
Each person you appoint (named in Section 1) completes this section. If the individual is not an attorney, he or she must provide his or her name, and state that he or she accepts the appointment, and signs the appointment.
Section 3: Waiver of Fee for Representation
Your representative will complete and sign this section if he or she will not charge any fee for the representation provided.
Section 4: Waiver of Payment for Items or Services
Your doctor or provider may complete and sign this section if they will not charge you for items and services already received (if they are not covered by Medicare).
CHP members must submit their completed form via one of the options below:
Mail:
Capital Health Plan
Attention: Member Services
P.O. Box 15349
Tallahassee, FL 32317-5349
Deliver:
Capital Health Plan
Member Services
1264 Metropolitan Blvd.,
Tallahassee, FL 32312
Fax:
(850) 383-3413
Important Information
An appointment of a representative is considered valid for one year from the date this form is signed by both the person appointing a representative and the appointed representative. A completed form can be used for other appeals or actions during the one-year period it’s valid. Unless revoked, the representation is valid for the duration of the claim, appeal, grievance, or request for which it was filed.
A new form must be submitted with each grievance and appeal you submit.
Capital Health Plan Silver Advantage (HMO), Advantage Plus (HMO), Preferred Advantage (HMO), and Retiree Advantage (HMO) are HMO plans with a Medicare contract. Enrollment in Capital Health Plan Silver Advantage, Advantage Plus, Preferred Advantage, and Retiree Advantage depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
If you have questions, please call Member Services at (850) 523-7441 or 1 (877) 247-6512 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1 (877) 392-1532, 7:00 a.m. – 7:00 p.m. TTY/TTD (850) 383-3534 or 1 (877) 870-8943.