Medicare Plans
Appointing/designating 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.
Y0083_2024ABM_AEP_WEBPAGES_M CMS Approved
Last updated 10/01/2023
To file a marketing complaint about a sales agent or broker, call 1-800-MEDICARE or the plan’s Customer Service number. When you call, it’s important to provide the agent’s or broker’s name, if possible.