How to appoint a representative

Part C appeal requests

We must have authorization to review a Part C reconsideration request from someone other than the member, or the member's doctor (pre-service requests only).

  • You can appoint anyone to act on your behalf by sending us an Appointment of Representative Form, PDF opens new window. You and your representative must sign the form for it to be valid.
  • A representative who is appointed by the court or who is acting under state law can also file a request for you after sending us the legal representative form. You don't need to complete an Appointment of Representative Form if you send another legal representation document with your request.

Part D appeal requests

We must have authorization to review a Part D or redetermination request from someone other than the member, their prescribing doctor, or other prescriber.

  • You can appoint anyone to act on your behalf by sending us an Appointment of Representative Form, PDF opens new window. You and your representative must sign the form for it to be valid.
  • A representative who is appointed by the court or who is acting under state law can also file a request for you after sending us the legal representative form. You don't need to complete an Appointment of Representative Form if you send another legal representation document with your request.

Grievance requests

We must have authorization to review a grievance request from someone other than the member.

A representative who is appointed by the court or who is acting under state law can also file a request for you after sending us the legal representative form. You don't need to complete an Appointment of Representative Form if you send another legal representation document with your request.

Appointment of a representative

Download the Appointment of Representative Form below:

Appointment Authorized Representative Form – English , PDF opens new window

Appointment of Representative Form – Spanish , PDF opens new window

You also can get the Appointment of Representative Form on CMS' website, opens new window.

Refer to Chapter 9 of your Evidence of Coverage (EOC) for more information about the grievance and appeals processes.

Multi-Language Interpreter Services , PDF opens new window