- Evidence of Coverage
- Summary of Benefits
- Formulary
- Grievances & Appeals
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Directories - LIS Premium Summary Chart
- Disenrollment Rights
- Appointing a Representative
- Health Care Proxy (PDF)
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.
If you would like more information about appointing a representative, or if you would like to obtain a representative form, please contact Member Services. We are open weekdays, Monday through Friday, from 8 A.M. to 8 P.M., and also on Saturdays and Sundays from October 15th to February 14th. Interpreter services are available upon request.
- 1-888-794-7268 (toll-free)
- 711 (TTY)
Last modified: 12/22/2011