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Appointment of Representative

Appointment of Representative Form Instructions

You can name another person to act for you as your “representative” to assist with any health plan related activity including:

  • Ask for a coverage decision
  • File a grievance
  • Make an appeal on your behalf

Your designated representative will have the same rights as you do in any health plan related activity, including asking for a coverage decision, filing a grievance, or making an appeal. This person can be a relative, friend, doctor, or anyone else whom you trust to act on your behalf. If you want to appoint someone to act for you, then both you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. We must receive this written statement before providing any information to your representative, including initiating any coverage decisions or appeal requests that your representative makes on your behalf.

How do I appoint a representative?

To appoint a representative, you must complete an Appointment of Representative Form (English | Español | Large Print Form). At the top, enter your full name and Medicare number. If you appoint more than one person, please complete a form for each of them.

Section I: Appointment of Representative

Give the name and address of the person you’re appointing. You may appoint a relative, friend, advocate, attorney, your physician, or any other qualified person to represent you. Additionally, you must date and sign this section as the beneficiary, providing your address and phone number as well.

Section II: Acceptance of Appointment

Each person you appoint (named in Section I) completes this section. If the individual isn’t an attorney, they must provide their name and state their acceptance of the appointment, signing the form as well.

Section III: Waiver of Fee for Representation

Your representative may complete and sign this section if they won’t be charging any fees for their representation. Remember that a new form must be submitted with each grievance and appeal you submit.

Please fax or mail the form to:
P.O. Box 211025
Eagan, MN 55121

Fax: 1-312-277-9246

For incapacitated or legally incompetent enrollees for whom there are appropriate legal papers or other legal authority, supporting documentation may be submitted as evidence of representation.