Appointing a Representative

According to Medicare guidelines, an appointed representative is a person who can act on your behalf to request an exception, appeal or grievance. This person can be a relative, friend, advocate, doctor, or anyone else whom you trust to act on your behalf. If you want to appoint someone to act for you, then both you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. Physicians and other prescribers who are providing your treatment may, upon providing notice to you, request for a pre-service redetermination on your behalf without completing an Appointment of Representative (AOR) form.

The signed AOR form or other equivalent notice must be included with each oral or written request for an appeal or grievance. Unless revoked, an appointment is considered valid for one year from the date that the representative form is signed by both the Member and representative. Also the representation is valid for the duration of the appeal or grievance. A photocopy of the signed representative form must be submitted with future appeals or grievances on behalf of the Member in order to continue representation. However the original or photocopied form is only valid for one year after the date of the Member's signature.

Send you statement to the following address:

Part C (and Part B Drugs) Appeals, and Part C and Part D Grievances:
Appeals and Grievances Dept.
P.O. Box 279410
Sacramento, CA 95827

Fax: 1-844-273-2671

Part D Appeals:
Appeals and Grievances Dept.
P.O. Box 31383
Tampa, FL 33631-3383

Fax: 1-866-388-1766

You can use the AOR form below or you can make your own statement (an equivalent written notice) as long as it contains all the required information.

Fill out Form

Link to the Centers for Medicare and Medicaid Services (CMS) 
Appointment Of Representative Form CMS-1696
 (By clicking on this link you will be leaving the Allwell from Arizona Complete Health website.)

In addition, we may also accept other forms of legal documentation.

The required information of an 'equivalent written notice' is one that:

  • Includes the name, address, and telephone number of enrollee;
  • Includes the enrollee's HICN [or Medicare Identifier (ID) Number];
  • Includes the name, address, and telephone number of the individual being appointed;
  • Contains a statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative;
  • Is signed and dated by the enrollee making the appointment; and
  • Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment.

If you need assistance in naming your appointed representative, please contact Member Services.