Appointment of Representative

If you wish, you can appoint someone to act for you and communicate with us on your behalf about your care and benefits. This can be a relative, friend, a healthcare professional or lawyer, or any other person or organization you want to represent you. To do so, you must complete, sign and send us an Appointment of Representative form that gives that person or organization permission to speak with us and make decisions for you.

If you need help filling out the form or want to learn more about appointing a representative, you can call us at 1‑800‑373‑3177 (TTY/TDD: 711), seven days a week, 8 a.m. to 8 p.m.

Appointment of Representative Form – English
Appointment of Representative Form – Spanish

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