Do you need someone to file a complaint or appeal for you? If so, this document allows you to name someone to make decisions for you. This person may be a spouse, family member, friend, lawyer or caregiver.
Make sure you have your Medicare number. Print or type your number and name on the top of the form.
Appoint at least one person to act on your behalf. You can name more than one. If you do, you will need to complete a form for each person.
Each person you appoint needs to complete the Acceptance of Appointment section. They provide their names and state where they accept the appointment.
The person or people you name should fill out the Waiver of Fee for Representation part of the form if he or she is not charging you for acting on your behalf.
H9826_IT_10045_092919_M Last updated December 06, 2023.
As a local nonprofit health plan, Community Health Choice gives you plenty of reasons to join our Community. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, Community is always working life forward for you and your family.
“Community Health Choice is always there to answer my questions and help me and my family with our medical needs. I truly appreciate and value their customer support and service.”– Cecily
Member of Community Health Choice