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- Disenrollment Rights
- Appointing a Representative
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Appointing a Representative
You have the right to appoint a representative (such as a relative, friend, advocate, attorney, physician, etc) to act on your behalf. Both you and the person you have named as an authorized representative will need to sign the representative form, unless your representative is a lawyer. In that case, only your signature is needed. If your prescribing doctor calls on your behalf no representative form will be required.
Please click on the link below to access the Appointment of Representative Form (CMS-1696).
Download the Appointment of Representative
Form (CMS-1696) (PDF)
To download the Appointment of Representative Form, you must have Adobe Acrobat Reader installed. If you do not have Adobe Acrobat Reader installed on your computer, click here to download and install a free version of Adobe Acrobat Reader or click on the Adobe Acrobat Reader icon below.
To search an Adobe PDF file using Adobe Acrobat Reader, click on the "Search" icon (the button with the binoculars) on the Acrobat file toolbar or choose "Edit > Search" from the Acrobat menu. In the "Search PDF" window that opens, type in the word or phrase you are looking for and click on "Search".
The cursor will jump to the first place in the document that word or phrase appears and a search results box will also appear listing all the occurrences of that word or phrase. You can jump to any particular instance of the word or phrase by clicking on that item in the results box. You can also use the "Edit > Search Results > Next Result" or "Edit > Search Results > Previous Result" in the Acrobat menu to navigate forwards or backwards to the next item.
If you would like more information about appointing a representative, or if you would like to obtain a representative form, please contact Member Services. Our hours of operation are weekdays, Monday through Friday, from 8AM to 8PM, and also on Saturdays and Sundays from November 15th to March 1st. Someone is available, however, 24-hours a day, if assistance is needed. Interpreter services are available upon request.
- 1-888-794-7268 (toll-free)
- 1-888-749-6455 (TTY)
Last modified: 04/01/2010