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Instructions on Appointing a Representative Enrollee’s may appoint any of the following to act as his/her representative: relative, friend, advocate, attorney, physician, employee of a pharmacy, charity, state pharmaceutical assistance program. A representative who is appointed by the court or who is acting in accordance with Florida law may also file a request for a coverage determination or appeal on behalf of an enrollee. A surrogate may include: a court appointed guardian, an individual who has Durable Power of Attorney or health care proxy, or a person designated under a health care consent statute. With the exception of an incapacitated or legally incompetent enrollee, where legal papers or other legal authority support representative or where a state’s authorized representative rules require otherwise, both the enrollee making the appointment and the representative accepting the appoint must sign, date, and complete an Appointment of Representative form or similar written statement. If the appointed representative is an attorney, only the enrollee needs to sign the form or similar statement. The enrollee may also use an “equivalent written notice” if the information in the written notice includes the enrollee’s name and Medicare number. The Appointment of Representative form (CMS-1696) may be printed by the link below and printing the form for your use.
Once a signed form or other statement has been submitted, the enrollee is not required to obtain a new signed form or statement for the life of the appeal. An enrollee is not required to obtain a new signed form or statement for any new appeal filed by the representative within one calendar year from the date that a valid signed form or statement is executed. However, the appointed representative must file a copy of the original form or statement with each new request for a coverage determination or redetermination.
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