Appointment of Representative Form Instructions
You can name another person to act for you as your "representative" to:
- 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 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 initiating any coverage decisions or appeal requests that your representative makes on your behalf.
To appoint a friend, relative, or other person to be your representative, you have two options:
Complete an "Appointment of Representative" form. You can download and print this form from our website, or call Member Services and ask for the "Appointment of Representative" form. You can also get the form on the Medicare website (PDF). The form gives the person permission to act for you. You must give us a copy of the signed form.
Send us an equivalent written notice. You may write your own equivalent notice as long as it includes all of the required information below. If it does not include all of the information below, you will not be able to appoint a representative. A notice is an "equivalent written notice" if it:
- Includes the name, address, and telephone number of member.
- Includes the member’s HICN (or Medicare Identifier [ID] Number).
- Includes the name, address, and telephone number of the individual being appointed.
- Contains a statement that the member 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.
- Is signed and dated by the member making the appointment.
- Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment.
A signed form or notice must be included with each request for a coverage decision, grievance, or appeal made on your behalf. If you need assistance in naming your appointed representative, please call Member Services. You can mail or fax the completed form or an equivalent written notice to:
Keystone First VIP Choice
Attn: Appeals and Grievances Department
P.O. Box 337
Essington, PA 19029