APPOINTING A REPRESENTATIVE

If you’d like someone other than yourself to file your appeal or grievance, organization determination, or coverage determination on your behalf, you must complete and turn in to us an Appointment of Representative Form or a legal document stating you have chosen someone other than yourself to file for you. This will confirm that the individual has your permission to see all information including your medical records about the appeal and/or grievance.

Appointing a representative may be done at any point of the organization determination, coverage determination, or appeal or grievance process. You can appoint an attorney, or another individual, to help you and to act as your representative. An appointment of representative form, or the same request in a written request, will need to be completed by the person making the appointment. If using a written request, it must include all of the same information requested on the appointment of representative form. This appointment of a representative will expire one year from the signing date on the appointment form or written document of both you and the individual you are appointing.