Appointing a Representative

Appointing a Representative – Instructions & Form

People who want to represent a member can be appointed or authorized by the member.

A member can authorize anyone (like a relative, friend, advocate, attorney, or doctor) to act as his or her representative and file a grievance, appeal, or organization determination on his or her behalf.

A representative (or surrogate) can also be authorized by the court or act on behalf of the member in accordance with State law to file an appeal for an enrollee. A surrogate could include but is not limited to, a court-appointed guardian, an individual with Durable Power of Attorney, a healthcare proxy, or a person designated under a healthcare consent statute.

How to authorize a representative

The member must sign, date, and complete a representative form.

The person acting on behalf of the member must sign, date, and complete the same form.

Print and complete the Appointment of Representative form. If a member is incapacitated or legally incompetent a surrogate is not required to submit an Appointment of Representative Form. The surrogate will need to give Clever Care Medicare Advantage copies of the legal papers supporting his or her status as the member’s authorized representative.

Clever Care Medicare Advantage requires a copy of the completed and signed Appointment of Representative Form to process a grievance, appeal, or organization determination filed by the member’s representative. The form will be valid during the entire grievance, appeal, or organization determination process. The Appointment of Representative Form is valid for one year from the date indicated. A member can revoke the authorization at any time.

Appointment of Representative form