Appointing a Representative

Members can appoint or authorize anyone to act on their behalf — such as a relative, friend, advocate, attorney, or doctor — to file a grievance, appeal, or organization determination.

A representative or surrogate may also be authorized by a court or under State law to file appeals. Surrogates can include court-appointed guardians, individuals holding Durable Power of Attorney, healthcare proxies, or persons designated under healthcare consent statutes.

How to Authorize a Representative

Both the member and the person acting on their behalf must sign, date, and complete a representative form.

Print and complete the Appointment of Representative form. If a member is incapacitated or legally incompetent, a surrogate does not need to submit the form but must provide Clever Care Medicare Advantage with copies of legal documentation supporting their status.

Clever Care Medicare Advantage requires a signed Appointment of Representative Form to process grievances, appeals, or organization determinations filed by the representative. The form remains valid throughout the entire process and is valid for one year from the date indicated. Members may revoke the authorization at any time.

The Appointment of Representative form (CMS-1696) is available on the CMS website.

This page was last updated on October 24, 2025.