Use this form to appoint a representative to act on your behalf for your claim, appeal, grievance or request. By signing this form and appointing this representative, you agree that the representative will be the main contact and have authority to make requests, present evidence, get information, and receive all communication about your action. This person may see your personal medical information.
Section 1: Information about the person appointing the representative
This section must be completed by the patient, provider or other person appointing a representative.
