Appointing a Representative

Members can appoint or authorize someone 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 may include:

• Court-appointed guardians
• Individuals with Durable Power of Attorney
• Health care proxies
• Individuals designated under applicable health care 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.

Download and complete the Appointment of Representative Form (CMS-1696):
https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms1696.pdf

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 on the form. Members may revoke the authorization at any time.

You may download, print, and complete the Appointment of Representative Form (CMS-1696) using the link above before submitting your grievance, appeal, or organization determination request.