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. To appoint a representative you must complete an Appointment of Representative Form.
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.
How to Complete This Form
Please print or type. At the top, show your full name and Medicare number. If you appoint more than one person, you may want to complete a separate form for each of them.
Section 1: Appointment of Representative
Give the name and address of the person 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 I) completes this section. If the individual is not an attorney, he or she must provide his or her name, state that he or she accepts the appointment, and sign the appointment.
Section 3: Waiver of Fee for Representation
Your representative may 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).
A new form must be submitted with each grievance and appeal you submit.
Download the form needed to appoint a representative: