An enrollee may appoint any individual (such as a
relative, friend, advocate, an attorney, or any physician) to act as his or her representative and file an appeal on his or her behalf.
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, 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 representative form. Due in part to an incapacitated status 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
A signed Appointment of Representative Form
(download link shown below), or an equivalent written notice which includes the following: Member's name, address, telephone, HICN, [or Medicare Identifier (ID)]; the individual being appointed name,
address, telephone number. It should also contain a statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s)at issue, and a statement authorizing
disclosure of individually identifying information to the representative. The notice is signed and dated by the enrollee making the appointment; and is signed and dated by the individual being
appointed as representative, and is accompanied by a statement that the individual accepts the appointment.
Regarding a representative appointed by an
enrollee, an appointment is considered valid for one year, unless revoked, from the date that the appointment is signed by both the member and the representative.
You may obtain a copy of CMS'
Appointment of Representative Form by clicking on the Medicare link below: