Appoint a Representative
Individuals who represent enrollees may either be appointed or authorized. An enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative in filing a grievance, requesting an organization determination, or in dealing with any of the levels of the appeal process. Also, a representative (surrogate) may be authorized by the court or act in accordance with State law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute.
To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete a Appointment of Representative Form (CMS-1696 Form).
Due in part to the incapacitated or legally incompetent status of an enrollee, a surrogate is not required to produce a representative form. Instead, he or she must produce other appropriate legal papers supporting his or her status as the enrollee's authorized representative.
Either the signed representative form for a representative appointed by an enrollee, or other appropriate legal papers supporting an authorized representative's status, must be included with each appeal. Regarding a representative appointed by an enrollee, unless revoked, an appointment is considered valid for one year from the date that the appointment is signed by both the member and the representative. Also, the representation is valid for the duration of a grievance, a request for organization determination, or an appeal.
A photocopy of the signed representative form must be submitted with future grievances, request for organization determinations, or appeals on behalf of the enrollee in order to continue representation. However, the photocopied form is only good for one year after the date of the enrollee's signature. Any grievance, request for organization determination, or appeal received with a photocopied representative form that is more than one year old is invalid to appoint that person as a representative and a new form must be executed by the enrollee.
Instructions on how to appoint a Representative
Please note that only sections I, II, and III of the form apply to the Medicare Advantage program.
- Section I: Appointment of Representative section
The name of the representative is required. In addition, the Medicare Beneficiary must sign and date the form, and complete their address.
- Section II: Acceptance of Appointment section
The representative should enter their name in the 1st paragraph, identify their relationship to the beneficiary, sign and date the form, and complete the address / telephone section.
- Section III: Waiver of Fee for Representation Instructions
This section must be completed if the representative is required to, or chooses to waive their fee for representation.
- Section IV: Waiver of Payment for Items or Services at Issue
Does not apply to the Medicare Advantage Program.
H3528_18_4006_01 Approved 10/05/2017
Last Update 9/30/2017