Appointing a Representative to Act for You
PHP (HMO SNP) members may appoint any person such as a relative, friend, advocate, attorney, physician, or an employee of a pharmacy to act as his or her representative to file a grievance, request a coverage decision or exception, or request an appeal on their behalf.
If you would like to appoint a representative to act on your behalf, please download the Appointment of Representative Form (Form CMS-1696). (By clicking on this link, you will be downloading a file from the Centers for Medicare and Medicaid Services website.)
Please mail the completed form to Member Services. You may also fax the completed form to us.
We also accept written equivalents of this form that must include:
- Your name, address and telephone number
- Your Medicare number (found on your red, white and blue Medicare card)
- The name, address and telephone number of the person you are appointing to represent you
- A statement that says you are authorizing your representative to act on your behalf for the medical service(s) or claim(s) at issue
- A statement that you authorize disclosure of your personal health information to your representative
- Your signature and date
- A statement from the person you are appointing to represent you that says he or she accepts the appointment
- The signature and date of the person you are appointing to represent you
Members may also appoint a representative to act on their behalf under a durable power of attorney for health care or by another legal documentation. If you have any questions about appointing a representative to act for you, please contact Member Services.
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