SELECT AN OPTION: Member
An appointed representative is an individual appointed by you, or authorized by the state, or other applicable law, to act on your behalf in the grievance or appeals process. The person you name to be your appointed representative can be a relative, friend, advocate, or doctor.
Other persons may already be authorized under state law to act for you. If you want someone to act for you who is not already authorized under state law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative.
To access the Centers for Medicare & Medicaid's Appointment of Representation form, click here (published November 1, 2015).