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Appoint a Representative
Why Appoint a Representative?
You may appoint an individual (such as a relative, friend, advocate, attorney, physician,
or an employee of a pharmacy or charity) to act as your representative so
that they may file requests for a coverage determination or appeal on your behalf.
How to Appoint a Representative
In order to appoint someone as your representative, you and your representative must sign,
date and complete an Appointment of Representative form (CMS-1696). If the appointed
representative is an attorney, only the enrollee needs to sign the appointment of
representative form or similar statement. Except in the case of an incapacitated or
incompetent enrollee, a request for a coverage determination or re-determination from
an appointed representative is not valid until
supported with an executed appointment of representative form or statement.
Appointment of Representative form (CMS-1696) (PDF)
Designate Someone on My Behalf
If you would like to designate someone to speak on your behalf, please print and complete the appropriate form and mail to
Medi-Pak Advantage (PFFS) Privacy Office, P.O. Box 3835, Scranton, PA 18505. If you have questions regarding the designation process, please call 1-877-233-7022.
Designate someone to ask questions on my behalf (PDF)
H4213_Adv 2011 Website Submission CMS Approved 10182010
Web Page Last Updated: 8/20/2011
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