Tip for CMS model representative form

This form is required if someone other than you is filing an appeal with your MA plan

Tip for CMS model representative form

Attorneys, family members, or patient advocates can serve as your representative

Tip for CMS model representative form

A separate appointment may be needed at each appeal level (plan, IRE, ALJ, MAC)

Medicareeasy

MA/Part D Appointment of Representative

CMS model representative form · CMS

Authorizes another person to file grievances, request coverage determinations, or appeal on behalf of a Medicare Advantage or Part D enrollee.

Form Details

Total fields: 18
Auto-fillable: 14 (78%)
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Filled by: both
Frequency: as needed

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Where to Submit This Form

📬

Mail to your Medicare Advantage plan

Send to the plan's address on your membership card or correspondence.

📠

Fax to your MA plan's member services

Fax number is on the back of your plan membership card.

🏢

Submit at your MA plan's local office (if available)

Required Attachments

📎 Completed appointment of representative form signed by both the enrollee and representative
📎 Proof of representative's authority (power of attorney, court order, or health care proxy if enrollee is incapacitated)

Processing Time

Processed within 5-10 business days. The representative can begin acting once the form is accepted.

What Happens Next

The appointed representative can file appeals, request coverage determinations, and receive plan correspondence on your behalf.

Tips for This Form

✓ This form is required if someone other than you is filing an appeal with your MA plan
✓ Attorneys, family members, or patient advocates can serve as your representative
✓ A separate appointment may be needed at each appeal level (plan, IRE, ALJ, MAC)
✓ The appointment can be revoked at any time by written notice to the plan

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